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1 .0 <br /> BLI" DING PERMIT /'-'t,PPLICAT� �N <br /> CITY OF EVERETT PERMIT SERVICES <br /> V E R 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 1(E)PermitServices@everettwa.gov 1(W)everettwa.gov/permits <br /> Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> 'ROJECT SITE ADDRESS: sTREEr [ M IL 6 )l�l D&O�T.JVl/ PARCEL#: ) ;r[� <br /> CITY G�f C- T STATE l.�j•� ZIP 01A.9f71I <br /> )UITEIUNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION (if applicable): 0A ice T.A `')All c 1 <br /> ( f o oTN <br /> 'ENANT/BUSINESS NAME (if non-residential): <br /> _EGAL DESCRIPTION for new construction: Short Plat/subdivision:f'At-000 o NI Lot No.: (attach copy of long legal description) <br /> CONTACT INFORMATION <br /> 7WNER NAME: t \i LOILLl2( 1-1.L <br /> )WNER MAILING ADDRESS: STREET P, C) C CITY i A 1 � ��;�j C_ ) STATE W A ZIP <br /> 7WNER PHONE: ZS _ GOn Col� OWNER EMAIL: PA'11E1,(2f-)ht 0 .( ,1✓l <br /> 'ONTRACTOR COMPANY NAME: S I!V <br /> ,1A STATE CONTRACTOR LICENSE#(REQUIRED): C�f%1 �.fl j�nt; CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): <br /> .'ONTRACTOR ADDRESS: STREET C��.�rb'C; <br /> CITY LAo�1 r—e S/EVL)\IS STATE 1rJ/4 Z1P <br /> 'ONTRACTOR PHONE: ta'25=SU�i�� UPS CONTRACTOR EMAIL: ►' \i1 IJaP/I(��7)?1fY �..f fill✓ <br /> RIMARY CONTACT: ❑OWNER ❑CONTRACTOR MOTHER(Please Specify) C.iS11 1. Q�Ih IN 2 <br /> ONTACT NAME: CONTACT PHONE: <br /> [ �t-`1�! ✓I�U�I�k�. �>` CONTACT EMAIL: <br /> BUILDING INFORMATION <br /> 'ALUATION OF WORK: $ Z� � , 0 C)C ASSOCIATED LAND USE PROJECT#(if applicable): <br /> aluat on shall include the prevailing fair market value of all labor,materials,and equipment needed to complete the work,whether actually paid or not.) <br /> XISTING USE OF BUILDING: r�I <br /> ROPOSED USE OF BUILDING: <br /> EAT SOURCE: ❑Gas 'gElectric ❑Other <br /> WILDING TYPE: COSFR ❑Townhouse ❑Duplex ❑ADU ❑Multi-Family-#Units: ❑Commercial ❑Accessary Structure <br /> YPE OF PROJECT(check all that apply): PNew Construction ❑Addition ❑Remodel ❑Repair ❑T.I. ❑Change of Use <br /> .�NOdular ❑Portable ❑Re-roof ❑Exterior Alteration ❑Tank(above ground) ❑Accessory Structure <br /> —]Fence over 7ft high ❑RackStorage ❑Pool/Hot Tub ❑Tank(above ground) ❑Other: <br /> SCRIPTION OF WORK:j� f�A S i" 't t M5 e- <br /> :;"KNOWLEDGEMENT.•1 have reviewed this application and confirm the information contained herein is true and correct. Work done pursuant to this permit must comply with <br /> c:!rrent 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 /> '.:ilding Official before being authorized under any circumstance.f am the owner,or f am authorized by the owner of this property to perform the work for which application is made, <br /> d I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> PERMIT# <br /> 61br-N-r) t���a��z <br /> rner/Authorized Agent Signature IDatd (Revised 4/21/2022)C/ / <br /> 7 <br />