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PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> 425-257-8810— FAX 425-257-8857—www.everettwa.org <br /> APPLICATIONS ARE ACCEPTED FROM 8 AM TO 4 PM � —IO��3 <br /> SITE ADDRESS <br /> PARCEL TAX I.D.# PERMIT# <br /> 4624 College Ave o0412000202500 ' � <br /> LECAL LOT NO. BLOCN TRACT <br /> DESC <br /> OWNER ADDRESS pTY21P PHONE <br /> Jim Rohlfing 4624 College Ave [vereu 98203 206-852-3846 <br /> TENANT NAME CONTACT FOR PERMIT PHONE <br /> INaida Khan 360-945-2787 <br /> CONTRACTOR H01110 D2P0�AY HOf112 S8NIC0S ADDRESS qTY21P PHONE <br /> 14a County Lin� Rd, #101 PACIFIC 800-381-5699 <br /> CONTR.LICENSE k HOMED**972RQ <br /> USE OF BUILDING HEAT SOURCE CONTRACT PRICE OF WORK <br /> SFR Electric _Gas_Other $7$60.00 <br /> WOR{< DESCRIPTION <br /> REPLACE 17 SQUARES OF COMPOSITE ROOFING. NO PLYWOOD REPLACEMENT <br /> PLUMBING MECHANICAL <br /> NO. TYPE OF FIXTURE OR ITEM NO. TYPE OF FIXTURE OR ITEM <br /> Toilet _ A/C—airhandlingunits <br /> Bathtub _ Forced air systems <br /> Lavatory (wash basin) _ Gas piping <br /> Shower ,_ Water heater <br /> Kitchen sink&disposal _ Gas fireplace <br /> Dishwasher _ Gas range <br /> Clothes Hasher _ Clothes dryer <br /> Laundry tray _ Range hood <br /> Sink(servicelbar/mopfetc.) _ Exhaustfan <br /> Backflow preventer _ Heat pump <br /> Urinal _ Unil heater <br /> Drinking Fountain _ Boiler <br /> Floor drain _ Refrigeration <br /> Grease trap _ Woodstwe <br /> Roof drains _ Other <br /> Other — <br /> CIN OF EVERETT LOCAL SALES TAX COOE I S 3105 <br /> I hereby ceritify that I have reatl and examined this appliwtion and hnowthe same to be true and correct. All prwisions of laws antl <br /> ortlinaces goveming this type of work will be complied wlth whether specified herein or noL The granting ot a permrt does not presume <br /> to give authority to viola[e or cancel lhe provision of any other slate or local law regulaling construction or the pedormance of <br /> construdion. That I am aulhorized by[h^ o�mer of Ihis property to perform the work tor whkh application is m�tle and I mmpty with the <br /> State Contractors Law 1827 RCW and 256200 WAC. ui9r��M�9 ��rN+����_� <br /> N a i d a Kh�n UN m•NaldaK�an o•NorthwestPerm;lnc.ou. <br /> _+aV�nalCa a mvMvn•kmT.c�US <br /> Signature of Owner/Contraclor/Authorizetl Agent Da:c:017((SYAI01:5991�0700' <br />