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BP '"-DING PERMIT APPLICA71N <br />CITY OF EVERETT PERMIT SERVICES <br />EVERETT <br />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 3 "S2 gE.0,410 PARCEL #: <br />CITY STATE ZIP 0 <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: Cp,sl S -rS p <br />OWNER MAILING ADDRESS: STREET <br />CITY STATE ZIP <br />OWNER PHONE: 206 - Z-24 - Q Z <br />OWNER EMAIL: A I 1_0T1,t5-Eel QT <br />CONTRACTOR COMPANY NAME: /VIZ • GoM <br />WA STATE CONTRACTOR LICENSE #(REQUIRED): (p D 2D -;--6 to S q <br />ICITY OF EVERETT BUSINESS LICENSE #(REQUIRED): K 3 6 S <br />CONTRACTOR ADDRESS: STREET 2.Cp 0 r rt4 <br />CITY STATE IVA ZIP <br />CONTRACTOR PHONE: <br />CONTRACTOR EMAIL: <br />PRIMARY CONTACT: ❑ OWNER CONTRACTOR ❑ OTHER (Please Specify) <br />CONTACT NAME: <br />S(� EjZI G{GSOM <br />CONTACT PHONE: 2 96 _-4­4.g - Itz <br />CONTACT EMAIL:is(�. lClGSv ftlLlD� S .CA <br />BUILDING INFORMATION <br />VALUATION OF WORK: $ Q 000 <br />ASSOCIATED LAND USE PROJECT # (if applicable): PkjJZZ0'5 �OfiZ <br />(Valuation shall include t1ie 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: <br />HEAT SOURCE: ❑Gas ❑Electric ❑Other <br />BUILDING TYPE: ❑SFR ❑Townhouse ❑Duplex ❑ADU ❑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: I6,o'lPo p=A-F-Y S HOP_W 6p <br />DESCRIPTION OF WORK: <br />'FigPOfLA y SFMPME ROvc/ FOR. Nt✓kx/ C01"PA-Ss H"cur-! 6u!CO!A14 <br />ACKNOWLEDGEMENT: I have reviewed this application and confirm the informalion contained herein is Into and correct. Work done pursuant to this permil 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. I am the owner, or I am 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 />0 Ll9120 <br />d Agent Signature Date (Revised 412112022) <br />