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BUILDING PERMIT APPLICATION <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 1-{S(Q S,L4 a 4,f, PARCEL#: [C)05-3� 00+2 -0J-ti—U d <br /> CITY Y zn'- STATE " • ZIP <br /> SUITE/UNIT M FLOOR M 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: �0 - Jn.t LLt; /9-lalj,J`-t- CJc(c�2i1 <br /> OWNER MAILING ADDRESS: STREET CH (p /VI r. Vi ,j - Ive , <br /> CITY Ov V,(,l l STATE / WOI • ZIP <br /> OWNER PHONE: t`_, �'- 7 - ) — OWNER EMAIL: /� I ��h�P.t !j'l�c. Lpr►1 <br /> CONTRACTOR COMPANY NAME: twe4f <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): <br /> CONTRACTOR ADDRESS: STREET <br /> CITY STATE ZIP <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> PRIMARY CONTACT: 16OWNER ❑CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: _ /' CONTACT PHONE: Gt a - '97 <br /> 1' <br /> 1 69f � <^ CONTACT EMAIL: <br /> BUILDING INFORMATION <br /> VALUATION OF WORK:$ Llo, ci c) ASSOCIATED LAND USE PROJECT#(if applicable): <br /> (Valuation shall include the prevailing fair market v lue 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: SE & <br /> HEAT SOURCE: ❑Gas ectric ❑Other <br /> BUILDING TYPE: &6FR ❑Townhouse ❑Duplex ❑ADU ❑Multi-Family-#Units: ❑Commercial ❑Accessory Structure <br /> TYPE OF PROJECT(check all that apply): ❑New Construction ❑Addition JNRemodel ❑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 /> 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 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> IA <br /> /'� ` PER T 'Z2.0S � Oe <br /> Owner/Au Torized Agent Signature D to (Revised 412112022) <br /> 0 y <br />