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PERMIT APPLICATION <br />CITY OF EVERETT PERMIT SERVICES <br />3200 CEDAR STREET, EVERETT, WA 98201 <br />425-257-8870 - FAX 425-257-8857 - www.everettwa.org <br />APPLICATIONS ARE ACCEPTED FROM 8 AM TO 4 PM <br />SIl E ADDRESS <br />3058 Bel,morr� Lane. <br />LEGAL LOTNO�� BLOCK <br />DESG i <br />OWNER <br />3���. N� h�s OnZ L1r <br />TENANT NAME <br />CONTRACTOR <br />CONTR. LICEN9E t <br />USE OF BUILDING <br />WORK DESCRIPTION <br />NO. <br />TYPE GF FIXTURE OR ITEM <br />Toilet <br />Bathtub <br />Lavalory (wash basin� <br />Sl�ower <br />Kitchen smk 8 disposal <br />Dishwasher <br />Clolhes washer <br />Laundry Iray <br />Sink (sernte/hadmoplelc � <br />Backllow preveider <br />Urinal <br />Drinking Fountain <br />Floor dram <br />Grease irap <br />Roof drains <br />Other <br />PARCEL TAl( I.D. N <br />TftACT �i 1 <br />�.�,� .i11'iil�'1 � t' - <br />ADD�iE9S <br />4 �SF.�IESc.:�e IQa 4 <br />CONTACT FOR PERMIT <br />3 � c�i �i�-a.V er5.� <br />ADDRES3 <br />HEATSOURCE <br />_ Elednc T Gas _ Other <br />iC # �-I PI2 <br />NO. I <br />U G�"� - <br />PER101T N „ <br />PHONE <br />'iL5-?5�{- IS�� <br />CITYZP PHONE <br />I CONTRACT PRICE OF WORK <br />TYPE OF FIXTURE OR ITEM <br />AIC - eir handling units <br />Forced air systems <br />Gas pipmg <br />Waler heater <br />Gas fireplace <br />Gas range <br />Clothes dryer <br />Range hood <br />E�haust lan <br />Heatpump <br />UNI heatei <br />Aoiler <br />Refngeration <br />Woodstove <br />CITV OF EVERETT LOCAL 9ALES TA% CODE IS ]106 <br />I hereby centRy Ihat I have read and ezammed this application and know the same to be trve and covect. All provisions nf laws and <br />ordmaces �oveming this type cf �.vork will be complied wilh whethe� speafied herein or not. The qranting of a pertnit does not presume <br />to give authonty lo violate or cancel Ihe provision ol any other state or local law regulatmg construdion or the pedortnance of <br />construc6on That I am authonzed by the owner of thls propeAy to perform the work for which epplication is made end I comply with lhe <br />State Contractors}.mr 1BRyRCW a A 29620J WAC. <br />�/ � <br />� , , ,:,"' � ! <br />Signature ol O r onlr8ctor uth d Agent ate <br />---- -- - . ...e_.--- �_ -------. — .. .- ---------�------- — <br />