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BL .DING PERMIT APPLICATIC, .. <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.govlpermits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET Lj 0 U-"S ,W PARCEL#: Q 0 2 -) <br /> CITY STATE ZIP <br /> SUITE/UNIT M. FLOOR#: ADDITIONAL LOCATION INFORMATION (if applicable): s j oTo'`t by F <br /> TENANT/BUSINESS NAME(if non-residential): <br /> LEGAL DESCRIPTION for new construction: Short Plat/subdivision:R At-(-i0 t~ �I I Y Lot No.: (attach copy of long legal description) <br /> CONTACT INFORMATION <br /> OWNER NAME: •-r L <br /> OWNER MAILING ADDRESS: STREET C.0 . 60A <br /> cm � STATE zip 9 <br /> OWNER PHONE: 425 : 50 2 5 _LJOWNER EMAIL: AUC <br /> CONTRACTOR COMPANY NAME: Tt -).S..S 11VC, <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): (ar' j' �j CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): <br /> CONTRACTOR ADDRESS: STREET ,0. t30' <br /> CITY r-e STATE W,4 ZIP 2Lj <br /> CONTRACTOR PHONE: '25— US CONTRACTOR EMAIL: q& <br /> PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR MOTHER(Please Specify)_C_i�Ll i. EN171N <br /> CONTACT NAME: CONTACT PHONE: -(,0, A2- <br /> CONTACT EMAIL: MAC� - t E �) <br /> BUILDING INFORMATION <br /> VALUATION OF WORK:$ ZIP I U 0 U ASSOCIATED LAND USE PROJECT#(if applicable): jeeV 122 O Z <br /> (Valuation shall Include the prevailing fair market value of all labor,materials,and equipment needed to complete the work,whether actually pald or not.) <br /> EXISTING USE OF BUILDING: NIA <br /> PROPOSED USE OF BUILDING: Ei pooc& <br /> HEAT SOURCE: ❑Gas JAElectric ❑Other <br /> BUILDING TYPE: 98FR ❑Townhouse []Duplex ❑ADU ❑Multi-Family-#Units: ❑Commercial ❑Accessory Structure <br /> TYPE OF PROJECT(check all that apply): YNew Construction ❑Addition ❑Remodel ❑Repair ❑T.I. ❑Change of Use <br /> ❑Modular ❑Portable ❑Re-roof El 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 /> Pr"'fosCP srr- Lod a <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 /> 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 I comply with the State Contractors Law 16.27 RGW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> C/t r �3y 2 p <br /> PERMIT# n �'LU-7 — D 9 <br /> � <br /> Owner/Authorly d Agent Signature ' Dat <br /> � (Revised 4/21/2022) / <br /> ly <br />