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P�RMIT APPLICATIOnI <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 - DEBIT 8 CREDIT CARDS ARE NOT ACCEPTED <br /> SITE ADORESS PARCEL TAX I.D.M PERMIT� <br /> ��� �no��, � �: mosoy_c <br /> LEGA LOT NO. BLOCK TRACT <br /> DESC. <br /> OWNER ADDRESS CITYlLIP PHONE <br /> % ,� 7 ��CR►M/-�N s cnr �{// C�z6w,� D�i Evf l�za3 y zs - 3 �r�- o�� <br /> TENANTNAME I CONTACTFORPERMIT PHONE <br /> S�w�� <br /> CONTRACTOR �'R R F-T- a U UES �DRESS CITY/ZIP PHONE <br /> CONTR.LICENSE N <br /> USE OF BUILDING I — HEAT SOURCE I CONTFt�.:T PRICE OF WORK <br /> Electric Gas_Other <br /> WORK DESCRIPTION <br /> 2 F E �LA�C NSE ? S hs�� (I ��`� o <br /> F�UMBING MECHANICAL <br /> NO. TYPE OF FIXTURE OR ITEM NO. TYPE OF FIXiLRE OR ITEM <br /> Toilel A/C—air handling units <br /> Bathtub Forced air systems <br /> Lavatory(wash basin) Z Gas piping <br /> Shower Water heater <br /> Kitchen sink 8 disposal Gas fireplace <br /> Dishwasher Gas range <br /> Cbthes washer Clolhes dryer <br /> Laundry tray Range hoad <br /> Sink(servicelbar/mop/elc.) Exhaust fan <br /> Backflow preventer Heat pump <br /> Urinal Unit healer <br /> Drinking Founlain Boiler <br /> Floor drain Refrigeretion <br /> Grease trap Woodstove <br /> Roo(drains Other _ <br /> Olher <br /> CITY OF EVERETT LOCAL SALES 7AX CODE IS J105 <br /> I hereby ceriti;i that I have read and examined this application and know the same to be true and correct. All provisions of laws and <br /> ordinaces goveming this type of work will be complied with whelher specified herein or not.The granting of a permit does not presume <br /> to give authority to viola e or cancel lhe provision of any other state o;local law regulating constniction or the performance of <br /> construction.That I a authorized by the owner of lhis property lo perfortn the work for which applicaUon is made and I comply with the <br /> St C ntra r , w 1827 RCW and 296.200 WAC. <br /> �//9 �s`� <br /> Signa ure o Owner/ ontractodAuthorized Agent Date <br />