12800 19TH AVE SE 2025-10-27 - Laserfiche WebLink

BUIL __4G PERMIT APPLICATION, 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 1 (E) PermitServices@everettwa.gov I (W) everettwa.gov/permits (Blue or Black Ink Only Please) PROJECT SITE INFORMATION PROJECT SITE ADDRESS: STREET 12800 19th Ave SE PARCEL #: 28053000407201 cnv Everett STATE WA z,P 98208 SUITEMNIT #: Lobby FLOOR #: 1 ADDITIONAL LOCATION INFORMATION (if applicable): TENANT/BUSINESS NAME (if non-residential): Providence Health and Services LEGAL DESCRIPTION for new construction: Short Plat/subdivision: See Attached Lot No.: (attach copy of long legal description) CONTACT INFORMATION OWNER NAME: Providence Health And Services OWNER MAILING ADDRESS: STREET 1321 Colby Ave CITY Everett STATE WA ZIP 98201 OWNER PHONE:425-218-0919 OWNER EMAIL: james.grafton@providence.org CONTRACTOR COMPANY NAME:SUrl Mit Commercial Construction LLC WA STATE CONTRACTOR LICENSE #(REQUIRED):CCSUMM1 CC837L8 �j� CITY OF EVERETT BUSINESS LICE E #(REQUIRED): � / O CONTRACTOR ADDRESS: STREET9700 Harbour Place (Suite 125) crry Mukilteo STATE WA zIP 98275 CONTRACTOR PHONE:425-533-8204 1CONTRACTOR EMAIL: peter@summltccllc.com PRIMARY CONTACT: El OWNER ❑ CONTRACTOR ❑ OTHER (Please Specify) CONTACT NAME: Jim Grafton CONTACT PHONE:425-218-0919 CONTACT EMAIL: james.grafton@providence.org BUILDING INFORMATION VALUATION OF WORK: $170K 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: Medical Office PROPOSED USE OF BUILDING: Medical Office 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 EIRemodel ❑Repair RT.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: Remodel Of exisiting reception area. LLL�� FEB 2 4 2024 a CI -Ty ® Services Pennt Se X f=G MENT: I have reviewed this a plicatice and confirm the information contained herein is true and correct. Work done pursuant to this permit must comply with federal, s ate, and local law. The granti of a permit only authorizes approved work and no deviations therefrom. Deviations must first be authorized in writing from the ling Official fore being authorized and ny circumstance. 1 am the owner, or I am authorized by the owner of this property to perform the work for which application is made, I comply wiflilthe Sta a Contra rs a i .27 RCW and 296.200A WAC. City of Everett Official Use Only 2/23/2024 PERMIT # 2 q 0 ier/Authorized A ent Signature Date (Revised 412112022)