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F cRM�T APPLICp►TIUN <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREEf, EVERETT, WA 98201 <br /> 425-257-8810- FAX 425-257-8657 -w�vv•everettwa.org <br /> APPLICATIONS ARE ACCEPTED FROM 8 AM TO 4 PM ( �-(� _�D <br /> SITE ADDRESS PARCEL TAX I.D.# PERMIT M <br /> 38�3G Grl.� � �1r.'E G�O��///,3m��c7l 70��`� r�r�/-(7U5 <br /> L[CAL LOT NO. BLO K TRACT OR SUB�IV1510N k <br /> o�s� 7 ,� y,���-��� <br /> OWNER ADDRESS CI7"YIZIP PNON " <br /> �D�Z, f�`/p�t/ Gf1URNC� :3F3.:�'1 G�-'.�'3t�r�.� �/= -i��9- 9�1..0/ <br /> TEHANT NAME CONTACT FOR PERMIT PHONF�� -�L <br /> �R /� Y�it/ CI�U�4NC� I�r�i��K c�i T'E�Iy1�� E-M�-rz�t�✓e;`a'''_ I <br /> � �Z� -TH�- <br /> CONTR.LICENSE N <br /> USE OF BUILDIIJG HEAT SOURCE �ONTRACT PRICE OF WORK <br /> ��N�p C , ����C� _Elednc _Gas�Other <br /> � <br /> WORK DESCRIPTION �/,�'� <br /> .�� <br /> � -- <br /> ,- �1 . <br /> PLUMBING MECHANICAL <br /> N0. TYPE OF FI%TURE OR ITEM � NO. TYPE OF FIXTURE OR ITEM <br /> Toile� A/C -air handling uni�s <br /> BathWb Forced air sys�ems <br /> Lavatory(wash basin) Gas piping <br /> Shower Water heater <br /> Kitchen sink&disposal Gas tneplace <br /> Dlshwasher Gasrange <br /> Clothes washer Clothes dryer <br /> Water healer Range hood <br /> Sink (service/badmop/etc.) [xhauel fan ' <br /> BackOow prevenler Heal pump <br /> Urinal Unll hea�er <br /> Drinkiny Pountain Boiler i <br /> Ploor dram Refrigeration <br /> Grease trep Woodstove <br /> Roof drains Other <br /> Other <br /> I _' <br /> CITY OF EVERETT LOCAL SALES TAX CODE IS�105 <br /> I hereby cerlAy ihat I have reaA and exammed this app6wtion and know the same to be true and correct. All provisions of laws a�d <br /> ordinances goveming�his lype of work will be complied wdh wtiether specdied herein oi nol. The granting of a permi�doas not presume <br /> to give authonty lo violate ur cancel the provis�on ol any other state or local!aw requlating con�WCion or the performance of <br /> censtruction.That I am authorized by the owner o1 this property to perf�rm the worY,for which application Is made and I comply with the <br /> Slate Contrartors Law 1827 RCW and 296 2001NAC <br /> �ignature oi O�rneNContractorlAuthonzed Agent Uate <br /> / � �� <br />