|
�
<br />��,, ��
<br />����
<br />�
<br />_ __ .._ . _ ..
<br />. , . . , . . , �
<br />CITY OF EVERETT PE(�MIT SERVICES
<br />3200 CEDAR STREET, EVERETT, VItA 98201
<br />(P) 425-257-8810 ( FAX 425-257-8857 [(E) everetteps�7a evereitwa.gov � www.everettwa.govlpermits
<br />PROJECT SfTE INFORMATtON
<br />PROJECT ADDR�SS: �._.' t.� % , /, � ",," `zi , r � �c. ,.- � �r.� -�,-� � � ,
<br />-� � ,� ,
<br />• 3 , �
<br />, � _ ,�- ,
<br />� � , . 1� � l,� £ �'e � �� = � �' w-
<br />BUILDING AREA (if residential, new construction, rertiodel, or addition) 5F
<br />BUfLDiNG TYPE: �FR-�ETACHED ❑ SFR-ATTRCHED � DUP�EX ❑ MULTI-FAMILY -# �F UNITS: 0 COMMERCfAL
<br />USE OF BUILDING: ,� �-� �: ,� �7 �,',��?�.z�.
<br />ELEGTR�ICAL APPI.MGAT10�1 �NFORMATION
<br />CONTF�ACT PRICE OF WOftK: � �`����L` ��`�
<br />NUMBER OF aEVtCE5 {if low valta e): �
<br />FiRE ALARM? O YE5 �"�NC)
<br />�
<br />ASSOCIATED BUI�DING PERMIT # it appiicable : 'i^'lf '`�`
<br />DESCRIPTION OF WORK: ��' .:t.�.-:� �tf�' 4' �-t"._s�=-�Z'`�"-t.-- c"G-�.�.C.��.�- :�7 ,-_:���.-a '�
<br />� CON7A�CT IN�ORMAT�ttIN � � � � �
<br />� p �
<br />OWNER NAME: ? ��,� ��-° j b�"�€. �'}�--�s -� ��; ir` -� �/ TENANT NAME (if Commercial}:
<br />e ,:�.
<br />QWNER MAILING ADpRESS, sraeEr t'�z�`' � m> ,��'(�,.,f.+'t �`=r?�'�.
<br />CITY �' V t, �i��J�%�,.( .1 SThTE C..C...' t�" � ZIP ��J �.:-'��' �'�
<br />OWNER PHONE: `JU�� `�v^�i��d�` - �'-{�c�"�' OWNEf2 EMAiL:
<br />CONTRACTOR NAME: �i� t'�£��`7'2 „t �%'C i"�"� �..
<br />CONTRACTOR ADDRESS: sr�ecr ft" � % x � > ;'i��L! �`� �'r`' r��' `�'
<br />� 1 � ���� � �
<br />errr � c�',�" fif 1� �,"�t->r�) sr„r� �,,G� ':-{..._ ziP
<br />,
<br />CONTRACTQR PHflNE: � ��� � -- ��� -� �� :�3 % CONTRACTOR EMAiL: ���G` � ,�"',��;�.,� � w ��^p�P�€�r ;u � `%f'C �k'r� � ����`�
<br />CONTRACTOR LiG. #{REQUIRCD}: /`�%��=Jf �`����� �� 5��� /� C17'Y OF EVERETT BUSINESS LIC. #(RECtUlRED): �'`' ���-�
<br />PRlMARY CdN7ACT: ❑ OWNER �ONTRACTOR ❑ OTHER (Please Specify)
<br />Gt7NTACT NAME: CONTACT FHONE: ,����, �1 ~ �,t`� ,�"„�,�-'�
<br />� �
<br />� .`S r,�� �� �T ,�-�"� GflP1TAGi ER�IAIL: � F
<br />r t. �,� F�3 7�`r'e:ar-� ., r'-"a�7 . �:>Gu; �- t'� � �`F,.,� � ���'�r
<br />sIGRE�,4tBNT T heraby eertify that ! havo rt�ad �nd ex,�mined tlNs applicaticul and know the same to be Uue and oart�ct, Aft provisiQns o/ �aws »nd ordinancas goveming lhis
<br />lype of work wilf 6e cornple7ed �vhetharspe�lf+ed ttetefn ar noE. 7'7ts g��r�frn� ol a p�rmit does not presume is� give �uthnYr(y to vroPata or cancet the provlsion& oi ar+y otfler siote ar
<br />1�crrJlaw reguiatirry ec�rlstnratiort or ttt� Rerlorma�nee of construet�orr. That 1 am aUthorizmd by tt�e owner of this property to ptrrforna the work far whtch application is mado r�nd t
<br />co�ripty �xr1h tho Stata Confrrrctars Law 98.27 R�W arrd 296.200 N/AC.
<br />�' � �r �
<br />� t l� , �� ,'.�:. �Y % t�-r�'� �!.-f' �.'� `�~ �..� �}`G� / G�'
<br />OwnerlAuthorizod Agent Signature Date
<br />City of Everatt QfJiCipt Usa Only
<br />FEE
<br />� ��' 00
<br />PERMIT #
<br />E1�05- ��1�
<br />(Revised y0112/2015)
<br />
|