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0 • <br />BUILDING PERMIT APPLICATION <br />CITY OF EVERETT PERMIT SERVICES <br />EVERETT 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 1 (E) PermitServices@everettwa.gov I (W) everettwa.gov/permits <br />(Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br />PROJECT SITE ADDRESS: STREET <br />/7� <br />O % PARCEL #:O0q ZZ f�0000(/ Oa <br />pp� pp <br />CITY •�1�) V STATE W 0 ZIP ? <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: j C, r f <br />OWNER MAILING ADDRESS: STREET <br />2!/l) (� <br />CITY �t�v{ re sTAr= ZIP q 62�I 72 <br />OWNER PHONE: <br />OWNER EMAIL: <br />CONTRACTOR COMPANY NAME: 60 ilmdahon 3 A O I S r' <br />WA STATE CONTRACTOR LICENSE #(REQUIRED): V Z- l PH <br />ICITY OF EVERETT BUSINESS LICENSE #(REQUIRED): <br />CONTRACTOR ADDRESS: STREET [yj r V)'rW Or <br />CITY Llrcm- STATE ' ZIP <br />CONTRACTOR PHONE: IJ2�- W - _Fa / J U7 <br />CONTRACTOR EMAIL: <br />PRIMARY CONTACT: ❑ OWNER CONTRACTOR L OTHER (Please Specify) <br />CONTACT NA/�ME: <br />�I N/ 6��/K I Lp d <br />CONTACT PHONE: 2GJ> �3-•� <br />CONTACT EMAIL: ,(s h ' Y41514600. net <br />BUILDING INFORMATION <br />VALUATION OF WORK: $ Z� 12Z5 U7 1ASSOCIATED LAND USE PROJECT # (if applicable): (� <br />(Valuation shall include the prevailing fair market value of all labor, materials, and equipment needed to complete the work. whether actually paid or not <br />EXISTING USE OF BUILDING: : <br />PROPOSED USE OF BUILDING: N� Gr IUI, <br />HEAT SOURCE: ❑Gas ❑Electric -]Other <br />BUILDING TYPE: ❑SFR LTownhouse ❑Duplex ❑ADU ❑Multi -Family - # Units: L ]Commercial ❑Accessory Structure <br />TYPE OF PROJECT (check all that apply) : ❑New Construction ❑Addition ❑Remodel Repair ❑T I ❑Change of Use <br />❑Modular ❑Portable ❑Re -roof ❑Exterior Alteration ❑Tank (above ground) ❑Accessory Structure <br />FIFence over 7ft high ❑RackStorage ❑Pool/Hot Tub ❑Tank (above ground) ❑Other: <br />DESCRIPTION OF WORK: i0ta(lana? o4� 7 ne1kO p)kef, 0 Pvst IogsG S-ircl C171-nvel 0" /0 <br />Sivk)1,14C A-Uu h4 t e a4;t�Y Se rjj ;,, <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 1 am the owner, or 1 am authorized by the owner of this property to perform the work for which application Is made, <br />4nd,omply with the State Contractors Law 18.27 RCW and 296.200A WAC <br />City of Everett Official Use Only <br />PER2? �2 Z ©'b1r/Auth i e Agent Signature Da e (Revised 412112022) <br />