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6 JILDING PERMIT APPLICAI iJN <br /> EVERETT <br /> CITY OF EVERETT PERMIT SERVICES <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 U I lf- (-P i 1 ' PARCEL#: <br /> CITY I Q�� - 1 V C.v <br /> STATE Zlp <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: 1 t <br /> OWNER MAILING ADDRESS: STREET 1 1L�y' -t�1iy fNC <br /> CITY V STATE q U <br /> ZIP <br /> OWNER PHONE: OWNER EMAIL: L1} + a m(*i Cl n-c+— <br /> CONTRACTOR COMPANY NAME: w n(' 1 DD <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): C{ 14,16TY OF EVERETT BUSINESS LICENSE#(REQUIRED). <br /> CONTRACTOR ADDRESS: STREET GI I IGI V ()� •. Al 1 CITY (/ �' STATE �\ ZIP ICU <br /> CONTRACTOR PHONE: �i -C� �C CONTRACTOR EMAIL: i <br /> �'� C -��4 C_�t c �1 <br /> PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: II II CONTACT PHONE: Li <br /> 1 6o C;VG1414�L � V1. 1�1� CONTACT EMAIL: <br /> BUILDING INFORMATION <br /> VALUATION OF WORK:$ ) r ASSOCIATED LAND USE PROJECT#(if applicable): <br /> (Valuation shall include the prevailing fair market va ue ofall 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 ElElectric ❑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: <br /> DESCRIPTION OF WORK: <br /> 1 <br /> Coc o eve - D IE IE 0 M <br /> NOV 2 7 2023 <br /> ACKNOWLEDGEMENT./have reviewed this application and confirm the information contained herein is true and correct. Work d*TP*tlanFto bE*EgZbmpy with <br /> current federal,state,and local law. The granting of a permit only authorizes approved work and no deviations therefrom.Deviation,?-must first Pe,agy trQrr;ed in tyriting from the <br /> Building Official before being authorized under any circumstance.l am the owner,or/am authorized by the owner of this property to perform th6 i ork for whiofi application is made, <br /> and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> / PERMIT# <br /> City of Everett Official Use Only <br /> I� <br /> e,Authorized , en Si ature Date (Revised 4/21r2 22) <br /> �I <br />