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Pit <br /> • • <br /> LI 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 /> WPSRINGTON then drop off completed application plus all required submittal documents to 3200 Cedar Street 2nd Floor Intake Drop Box. <br /> CONTACT INFORMATION:(P)425.257.88'10 1(E)everetteps@everettwa gov 1(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJIECT SITE ADDRESS: STREET 1118 80th St SW PARCEL#: 003922•-000-017-00 <br /> CITY Ever STATE WA ZIP 98203 <br /> jyITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION (if applicable): <br /> ITENANTfBUSINESs NAME(if 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 /> ""....".""" <br /> OWNER NAME: Crown Castle as Tower and Facility Owner <br /> OWNER MAILING ADDRESS: STREET 1505 Westlake Ave N, Suit 800 <br /> CITY Seattle STATE WA ZIP 98109 <br /> OWNER PHONE: (206)336-3204 _OWNER EMAIL: Sarah.Baird( crowncastle.corn <br /> —13 CONTRACTOR COMPANY NAME D--at-,MSSUaru Y frclo lt_ sd.. s. tk P <br /> WA STATE CONTRACTOR LICENSE#(REOUIRED)�pS[ S g� OF EVERETT BUSINESS LICENSE#(REQUIRED): 54.4 LA <br /> CONTRACTOR ADDRESS: STREET <br /> L-_-_ CITY STATE ZIP <br /> !CONTRACTOR PHONE: (CONTRACTOR EMAIL: <br /> PRIMARY CONTACT: 0 OWNER ❑CONTRACTOR ©OTHER(Please Specify) Crown Castle on behalf of AT&T <br /> CONTACT NAME: TCONTACT PHONE:802-777-3358 <br /> Emilie DeschamFs CONTACT EMAIL:Emilie@GMAnetworkservices.com <br /> _ -mInmems BUILDING INFORMATION <br /> ,....___„, --- —_.... 9 <br /> VALUATION OF WORK:$$25,000 ASSOCIATED LAND USE PROJECT#(if applicable): <br /> (Valuation shall include the prevailing fair market value Mall labor,materias,and equipment hesded to complete the work,whether actually paid or not.) I <br /> EXISTING USE OF BUILDING:U ^� <br /> PROPOSED USE OF BUILDING:NO change <br /> HEAT SOURCE: EGas ❑Electric ❑OtherN/A <br /> BUILDING TYPE: ❑SFR CTownhouse ❑Duplex ❑ADIJ ❑Multi-Family-#Units: ❑✓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 /> ❑Fence over 7ft high ❑RackStorage ❑Pool/Hot Tub ❑Tank(above ground) ❑Other:Wireless equipment modification <br /> DESCRIPTION OF WORK: <br /> Minor Modification to Existing Wireless Facility. F_FR Application. See Attached Project <br /> Description. <br /> LMINIMMINISp Milli.10111••• <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 /> cwrent 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.I am the owner,or I ant authorized by the owner of this property to perform the work for which application is made, <br /> and 1 comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> PERMIT# <br /> ' .Vt/(-4,,i� 0-el&----� 3/31/2022 EPERMIT# <br /> 1 ,7,0 q no. <br /> Owner/Authorized Agent Signature Date (Revised 2/8/2021) <br />