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EipLDING PERMIT APPLICAOJN <br /> CITY OF EVERETT PERMIT SERVICES <br /> EVERETT <br /> SUBMITTAL INSTRUCTIONS:See applicable submittal checklist for submittal requirements and number of copies required for review, <br /> WASHINGTON then drop off completed application plus all required submittal documents to 3200 Cedar Street 2nd Floor Intake Drop Box. <br /> CONTACT INFORMATION: (P)425.257.8810 I(E)everetteps@everettwa.gov I(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET 1,Z,�; be 41 g/9i21J Au( PARCEL#: � L <br /> CITY L�/ ( 1 ( ( STATE L.L..^., -- Zip v z. r. <br /> SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION (if applicable): <br /> TENANT/BUSINESS NAME(if non-residential): <br /> LEGAL DESCRIPTION for new construction: Short Plat/subdivision: Lot No.: (attach copy of long legal description) <br /> CONTACT INFORMATION <br /> OWNER NAME: fat sL l�_4 L// S <br /> OWNER MAILING ADDRESS: STREET A'l <br /> CITY STATE ZIP <br /> OWNER PHONE: 'JZS—1-11 sF,t �`] OWNER EMAIL: 5 v'l3 e' j t 1_yC e e <br /> CONTRACTOR COMPANY NAME: L,+, 1 FTS,i4}A,/ (G rL C <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED):C/ .k T',L' Z7 L, S CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): Q J D Li 7 <br /> CONTRACTOR ADDRESS: STREET / f t I7'*�' p <br /> �' Li• LL.Z [� <br /> CITY Lti STATE ['19 �J"ZIP 2 6 <br /> CONTRACTOR PHONE: �,� CONTRACTOR EMAIL: <br /> PRIMARY CONTACT: D INNER L7CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: 1 CONTACT PHONE: LPL.$ — C� 7 - y-6'j rf <br /> ✓/L' ) CONTACT EMAIL: SF i ',F <br /> BUILDING INFORMATION <br /> VALUATION OF WORK: $ Cr, (0/00 v ASSOCIATED LAND USE PROJECT#(if applicable): <br /> (Valuation shall include the prevailing fair market value of all la or,materials,and equipment needed to complete the work,whether actually paid or not.) <br /> EXISTING USE OF BUILDING: 5��F <br /> PROPOSED USE OF BUILDING:/ /L Pr- C=k <br /> HEAT SOURCE: ❑Gas C'11=1ectric ❑Other <br /> BUILDING TYPE: LISFR ❑Townhouse upl ❑ADU ❑Multi-Family-#Units: ❑Commercial ❑Accessory Structure <br /> TYPE OF PROJECT(check all that apply): hrNew Construction ❑Addition ❑Remodel ❑Repair ❑T.I. ❑Change of Use <br /> ❑Modular ❑Portable ❑Re-roof ❑Exterior Alteration ❑Tank(above ground) ❑Accessory Structure <br /> ❑Fence over 7ft high ❑RackStorage ❑Pool/Hot Tub ❑Tank(above ground) ❑Other: <br /> DESCRIPTION OF WORK: <br /> rht)t5'rI �' P c' F 1 j 64 rJt pk )G o �. <br /> xt'/.LD u . , <br /> S1� bLit i10000 & n I) <br /> ACKNOWLEDGEMENT.:I have reviewed this application and confirm the information contained herein is true and correct. Work done pursuant to this permit must comply with <br /> current federal,state,and local law. The granting of a permit only authorizes approved work and no deviations therefrom.Deviations must first be authorized in writing from the <br /> Building Official before being authorized under any circumstance.I am the owner,or I am authorized by the owner of this property to perform the work for which application is made, <br /> and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> PERM # <br /> 2203 —02J <br /> Owner/A thorized Agent Signature Date (Revised 2/8/2021) <br /> -L <br />