900 PACIFIC AVE BASE FILE 2025-08-14

B$ILDING PERMIT APPLICA1111514 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) PROJECT SITE INFORMATION PROJECT SITE ADDRESS: STREET 900 Pacifc Avenue PARCEL#: CITY Everett STATE WA ZIP 98201 SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION (if applicable): TENANT/BUSINESS NAME(if non-residential):Providence Hospital LEGAL DESCRIPTION for new construction: Short Plat/subdivision: Lot No.: (attach copy of long legal description) CONTACT INFORMATION OWNER NAME:Providence Health & Services OWNER MAILING ADDRESS: STREET 1321 Colby Avenue CITY Everett STATE WA ZIP 98201 OWNER PHONE:425-218-0919 OWNER EMAIL: CONTRACTOR COMPANY NAME:To Be Determined WA STATE CONTRACTOR LICENSE#(REQUIRED): CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): CONTRACTOR ADDRESS: STREET CITY STATE ZIP CONTRACTOR PHONE: CONTRACTOR EMAIL: PRIMARY CONTACT: 0 OWNER ❑CONTRACTOR ❑✓ OTHER(Please Specify) Architect(Owner's Rep) CONTACT NAME: CONTACT PHONE:425-259-0868 Devi n Saylor CONTACT EMAIL:devin@bnharch.com BUILDING INFORMATION VALUATION OF WORK:$167,000.00 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:Hospital/Outpatient Clinic(1-2 and B Occupancies) PROPOSED USE OF BUILDING:Hospital/Outpatient Clinic HEAT SOURCE: ❑✓Gas ❑Electric ❑Other 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.l. ❑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: Minor remodel of an existing point of care lab/supply room. 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 96.200A WAC. City of Everett Official Use Only 2405 5-2-24 PERMIT# ,/� 1 0 voi Owner/Authorized Agent Signature Date (Revised 4/21/2022)