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�ERMIT APPLICAT�JN <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> 425-257-8810— FAX 425-257-8857—w�,vw.everettwa.org <br /> APPLICATIONS ARE ACCEPTED FROM 8 AM TO 4 PM - DEBIT& CREDIT CARDS ARE NOT ACCEPTED <br /> SITE ADDRESS PARCEL TAX I.U.# PERMIT# <br /> I o m os r�a-o- <br /> LEGA LOT NO. BLOCK TRACT � <br /> DESC. <br /> OWi.ER ADDRESS CITYIZIP PHONE <br /> VGJ.r}YNG� ��(C5 <br /> TENANTNAME CONTACTFORPERMIT PHONE <br /> Ldi�l�c_�CS —� � �Y 1 I f��l�! �Lb ��'ZS� �Z— �J� �� <br /> CONTRACTOR ADURESS CITY21Ps P ONE <br /> EvERa�c:.-� �� ��c f �G z�z� ���F'c�. c�--� 4f�oi��+sJ zsz-arr� <br /> CON1R.LICENSE# , <br /> L'-v��ss o 2zc�-r <br /> USE OF BUILDING HEAT SOURCE CONTRACT PRICE OF WORK <br /> ot`/� �,SO oa <br /> A�� ��-y������ _Electric Gas_Other , <br /> WORK DESCRIPTION <br /> PLU;IABING MECHANICAL <br /> NO. TYPE OF FIXTURE OR ITEM NO. TYPE OF FDCTURE OR ITEM <br /> Toilet �, A/C-airhandiinyunils <br /> _ Bathtub Forced air systems <br /> _ Lavatory(wash basin) � Gas piping <br /> Shower Water heater <br /> _ Kitchen sink&disposal Gas fireplace <br /> _ Dishwasher Ga,range <br /> _ Clothes washer Clothes dryer <br /> Laundry tray Range hood <br /> i _ Sink(service/badmop/etc.) -� Exhaust fan <br /> _ Backflow prevenler Heat pump <br /> Unnal 3_ Unit heater <br /> � Drinking Fountain Boiler <br /> _ Floor drain Refrigeration <br /> Grease trap Woodstove <br /> Roof drains � Other�t�Jtaur'rurS��{�Z <br /> Other <br /> � CI7Y OF EVERETT LOCAL SALES 7AX CODE IS 3105 <br /> � I hereby ceritify that I have read and examined this application and know lhe same to be true and correct. All provisions of 12ws and <br /> ordinaces governing this type of work will be complied wilh whether specified herein or not.The granting of a permit does not presume <br /> to give authoriry to violate or cancel the provi,^ion of any other state or local law regulating constructlon or the performance of <br /> construction.T at I am authorized by the owner of this property to perform the work for which application is made and I comply with the <br /> State Co tr ors Law . W and 296.200 WAC. <br /> -Q � /–OS— i/ <br /> Signatu of Owner/ on rector/Authonzed Agent Date L <br />