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F cRMfT APPLICAT{JN <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STR�ET, EVERETT, WA 98201 <br /> 425-257-8810 - FAX 425-257-8857 <br /> SITE ADDRESS PARCEL TAX I.D.� PEFMiT a <br /> 4- � lti i�,�c'-,AT Y ►'�.c�z i -�c�4' <br /> LEGA LOTNO BLOCK TRACT <br /> DESC. <br /> OWNER qDDRESS ZIP PHONE <br /> h( V� itJ��,J F �L �h c_ /�v i E,����' `fZi 3.(�.3 S�/7 <br /> TENANTNAME I CONTACTNAME PHONE <br /> CONTRACTOR ADDRESS h ZIP CONTR.LICENSE N <br /> GV,�P/�. GONS�UG/70N ��vc z z9 i� d'6—i'/ c.,� ��o� L ULoPcci�oQ.v <br /> PHONE <br /> U-La 7� � -O� 7S- <br /> PROPOSED USE OF BUILDING BUIIdi�J I4� 'vlechanical Addi�ion HEAT SOURCE <br /> �/1 PERMI7 R Combination 1�`.-.�( Plumbing WORK R Alleiation n Electric <br /> 51� ,-C 1'YPE D Demolilion �,J Sign TYPE D New H Gas <br /> � ' � U Sprinkler U Repair/Maint. IJ Other <br /> CONTRACT PRICE OF WORK y� r,_Z� v' I O� CITY OF EVERETT LOCAL SALES TAX COOE IS 3105 <br /> -fr �r <br /> WORK DESCRIPTION � �.� � �� <br /> (,c,,,�C„c' �'�''� w�� o(,�.o� <br /> PLUMBING MECHANICAL <br /> NO. TYPE OF FIXTURE OR ITEPA NO. TYPE OF FIXTURE OR ITEM <br /> _ WATERCLOSET A!C—A/HANDLINGUNITS <br /> _ BATHTUB �_ FORCED AIR SYSTEMS <br /> _ LAVATORY(WASH BASIN) HEAT PUMP <br /> _ SHOWER _ UN!T HEATERS <br /> i = KITCHEN SINK& DISPOSAL _ CLOTHES DRYER <br /> DISHWASHER RANGE HOOD <br /> LAUNDRY TRAY _L WATER HEATER <br /> CLOTHES WASHER MFTAL FIREPLACE/STOVE <br /> I — URINAL _ FIREPLACE INSERT <br /> i __ DRINKING FOUNTA�N GAS FIREPLACE <br /> _ FLOOR DRAIN GAS RANGE <br /> _ BACKFLOW PREVENTER � GAS PIPNG �abb�ro, �O 3 <br /> �� _ SiNK (SERVICE/BAR/MOP/ETC.) _ EXHAUST FAN 1 �.�re <br /> OTHER OTHER <br /> i = _ - �,�^1�c,C�C'Q S <br /> `"C <br /> i — <br /> � — — <br /> I HEREBY CERI7IFY?HAT i HAVE READ AND EXAMINED THIS APPLICATION AND NNOW TF+E SAME TO BE TRUE AND CORRECT. ALL <br /> PRQVISIONS OF L1W5 AND ORIDINACES GOVERIJING THIS TYPE OF WORK WILL BE COM�LIED WITH WHE7HER SPECIFIED HEREIN OR <br /> NOT. THE GRANTING OF A PE�MIT�OES NOT PRESUME TO GIVE AUTHORITY TO VIOLATE OR CANCEL THE PROVISION OF ANY OTHER <br /> ' STATE OR LOCAL LAW REGUWTiNG CONSTRUCTION OR THE PERFORMANCE OF CONSTF•'�UCTION. THAT I F,M AUTHORIZED BY THE <br /> � OWN[R 0 THIS PROP�TQ PERFORM THE WOFK FOR WHICH APPLICATION IS MACE AND I COMPLY WITH THE STATE <br /> • CONTHA ORS LAW 1 27 RC N AND 296200 WAC. <br /> � � l�• 06 �oz <br /> ' Signal re of OwneuContrectodAuthorized Ac�ern Date <br /> r� �a�l-�c�8 <br />