2520 MADISON ST DISH WIRELESS 2025-08-08

as ILDING PERMIT APPLICATi7V CITY OF EVERETT PERMIT SERVICES EVERETT SUBMITTAL INSTRUCTIONS: See applicable submittal checklist for submittal requirements and number of copies required for review, WASHINGTON then drop off completed application plus all required submittal documents to 3200 Cedar Street 2nd Floor Intake Drop Box. CONTACT INFORMATION: (P)425-257-8810 I(E)PermitServices@everettwa.gov I (W)everettwa.gov/permits (Blue or Black Ink Only Please) g5g0 PROJECT SITE INFORMATION PROJECT SITE ADDRESS: STREET 2530'MADISON STREET PARCEL#: 28050800200100 CITY EVERETT STATE WA ZIP 98203 SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION (if applicable): TENANT/BUSINESS NAME(if non-residential):DISH Wireless LEGAL DESCRIPTION for new construction: Short Plat/subdivision: Lot No.: (attach copy of long legal description) CONTACT INFORMATION OWNER NAME:SUNRISE VIEW RETIRE VILLA INC OWNER MAILING ADDRESS: STREET 2530 MADISON STREET CITY EVERETT STATE WA zip 98203 OWNER PHONE:509.998.9015 TL1 e OWNER EMAIL: araymond@infinigy.com CONTRACTOR COMPANY NAME:TBD S i I\f Q t(' C/- L-LC WA STATE CONTRACTOR LICENSE#(REQUIRED):S l LVEL31 9 2.KB CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): CONTRACTOR ADDRESS: STREET CITY STATE ZIP CONTRACTOR PHONE: CONTRACTOR EMAIL: PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR ❑✓ OTHER(Please Specify) Applicant CONTACT NAME: CONTACT PHONE:509.998.9015 Angela Raymond with Infinigy CONTACT EMAIL:araymond@infinigy.com BUILDING INFORMATION VALUATION OF WORK:$40,000 ASSOCIATED LAND USE PROJECT#(if applicable): (Valuation shall include the prevailing fair market value of all labor,materials,and equipment needed to complete the work,whether actually paid or not.) EXISTING USE OF BUILDING:Wireless Communication Facility PROPOSED USE OF BUILDING:Wireless Communication Facility HEAT SOURCE: ❑Gas ❑Electric ❑Other N/A BUILDING TYPE: ❑SFR ❑Townhouse ❑Duplex ❑ADU ❑Multi-Family-#Units: ❑✓Commercial ❑Accessory Structure TYPE OF PROJECT(check all that apply): New Construction ❑✓Addition ❑Remodel ❑Repair ❑T.I. ❑Change of Use ❑Modular ❑Portable ❑Re-roof ❑Exterior Alteration ❑Tank(above ground) ❑Accessory Structure ❑Fence over 7ft high ❑RackStorage ❑Pool/Hot Tub ❑Tank(above ground) ❑Other: DESCRIPTION OF WORK: Dish is proposing to collocate on an existing WCF. There is an extension of19.6 feet proposed. All new ground equipment will be located within the existing leased area. For full scope of work see Sheet T-1 of construction drawings. 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 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 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, and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. City of Everett Official Use Only Digitally signed by Angela Raymond PERMIT# /� �O ,/) Je Angela Raymond Date 2022.08.1008:14:34-07'00' 8/10/2022 i�( 7 Owner/Authorized Agent Signature Date (Revised 4/21/2022) /Z