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r <br /> • <br /> • • <br /> MIMI <br /> In BUILDING PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> E 1►�/ER E T T 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`1(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET 2408 39th Street PARCEL#: 00576003200011 <br /> coy Everett STATE WA zip 98201 <br /> SUITE/UNIT#: FLOOR#: ADDITIONAL.LOCATION INFORMATION(if applicable): <br /> TENANTBUSiNESS NAME Of non-residential): Crown Castle on behalf of AT&T Mobility <br /> LEGAL DESCRIPTION for new construction: Short Plat/subdivision: Lot No.: (attach copy of long legal description) <br /> CONTACT INFORMATION <br /> OWNER NAME:Sheeler Jack <br /> OWNER MAILING ADDRESS: sTREET 8919 Eastview Avenue <br /> are Everett STATE WA LIP 98208 <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR COMPANY NAME- <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED 6/Ng, <br /> t, v�»tik C F - ICENSE#(REQUIRED): PO4�� <br /> CONTRACTOR ADDRESS: STREET <br /> CITY STATE ZIP <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR E OTHER(Please Specify) Crown Castle on behalf of AT&T <br /> CONTACT NAME: CONTACT PHONE:802-777-3358 <br /> Emilie Deschamps CONTACT EMAIL:Emilie@GMAnetworkservices.com <br /> BUILDING INFORMATION <br /> VALUATION OF WORK:$$25,000 'ASSOCIATED LAND USE PROJECT#(if applicable). <br /> (Valuation shall Include the preva�ng fair market value of an labor,materials,and equipment needed to complete the work,whether actually paid or not.) <br /> EXISTING USE OF BUILDING:U <br /> PROPOSED USE OF BUILDING:NO change <br /> HEAT SOURCE: ❑Gas DElectric ClOtherN/A <br /> BUILDING TYPE: OSFR OTownhouse ODuplex OADU OMulti-Family #Units: IZiCommercial OAccessory Structure <br /> TYPE OF PROJECT(check all that apply): ONew Construction DAddition ORemodel ORepair IZIT.I. ❑Change of Use <br /> OModular OPortable ORe-roof DExterior Alteration Drank(above ground) OAccessory Structure <br /> ©Fence over 7ft high ORackStorage OPool/Hot Tub OTank(above ground) mother.Wireless equipment modification <br /> DESCRIPTION OF WORK: <br /> Minor Modification to Existing Wireless Facility. EFR Application. See Attached Project <br /> Description. <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 /> currant 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.lam the owner,or I am authorized by the owner of this properly to perform the work for which application is made, <br /> and l comply with the State Contractors Law 18.27 RCW and 298.200A WAC. <br /> CityCi of Everett Official Use Only <br /> PERMIT#^ !�6`'� b I 0 <br /> OwnerlAuthorized Agent Signatu D tie 7/21 (Revlsed7/&/2021) <br /> 12_, _. <br />