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<br />� PERMIT APPLICATION�
<br />BUILpING / MECHANICAL / PLUMBING / SIGN I SPRINKLER / DEMOLITION
<br />CITY OF EVERETT PERMIT SERVICES
<br />3200 CEDAR STREET, CVERETT, WA 9920�1
<br />(P} 425-257-8810 � FAX 426-267-8967 �(E) everettepsQeveret�wa.pov � www.everettwa.Aov/permlfs
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<br />L�C3AL For new oonstru�tl0n; SI1o�l PlaUaubdivlelon Lot No..__ (altach oopy of Iong legel deacrlptlon)
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<br />dWNER NAME: � 1 '�{�� TENANT NAME (If Commerclal):
<br />OWNER MAILING ADDRESS:
<br />OWN�R PHON�:
<br />ONTRACTOR NAME:
<br />ONTRACTOR ADDR�98;
<br />srAeer �
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<br />BTREET
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<br />CONTI�ACYOR I'HONEr !--{-��,
<br />CONTRACTOR LICEN3E #(REQUIF
<br />PRIMARY CONTACT: ❑ OWNER
<br />CONTACT NAM�; ,,
<br />OWNER EMAIL:
<br />BTATE � �x - ZIP
<br />sTA� W 14� ZiP
<br />" �-2,7�0 CONTRACTOR EMAIL: 't-�'
<br />� f j � CITY OR �V�R�TT BU�INE69 LIC�NS�
<br />NTRACTOR ❑ OTH�F� (�leasa Speclfy)
<br />CONTACT PHONE; � �� �
<br />�CONiACT EMAIL: �Y�I.C>�Q t1`Cr1
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<br />Existin Use of 6ulldln ' Contrect Prlca of Work; � v� 1.
<br />Pro oeed Use of Bulldin ; Heat Source: as ❑Electric C�Other
<br />Bulldln T a: ❑5FR-Detached FR-Attechecl ❑Du Iex G1Multl•F�mfl -# of Units; ❑Comme�clal ❑Industrlal
<br />T e of Pro act: ❑New Addltion C]Fiemodel ❑Ro alr ❑T,I, C1SI n OS rinkler ❑Demolltlon ❑Chan e of Use
<br />DE3CRIPTION OF WORK;
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<br />A380CIATED BUIL NG PERMIT �i (If applicablol:
<br />ACKNOWLEDQEMENT: I have revlvwed Ihla appllcatlon end conflrnr the lnlormeflon conlalned hera/n (e trua end oorrecf. Work done pursuant �o thls parmR muat cvmply w/th
<br />curr�nf �ederel, sfe(a, and fooa!lew. 7he granfing of e parmlf only author7res epproved work end no davlaflona tNsreRnm. Davleflons muat lJrst be eufho�lzed In wriflnq /rom Ihe
<br />Bu!ldlnp ONl�/g� bsloig Belpg eufh0�lzed undar any clicumstm�ca, 1 em fhe awne� or / am euUiorized 6y tha owner v/ thls property to perlorm the work for whlch epp!lcetlon Is maCe,
<br />and f comply wlfh ffia 5tafe Contractor� L iB.2y RCW And 286.200.4 WAC.
<br />G/fy of E'vBreH Offici9l Use Onl
<br />� PERMIT t� n � �
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<br />OwnBY/Authorized Ageht I�natura Daig (Revlsed 1?2/201
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