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SITE AD S <br />LEGA LOT NO. <br />DESC. <br />OWNER <br />TENANTNAME <br />CONTRACTOR <br />CONTR. UCENSE A <br />USE OF BUILDING <br />WORK DESCRIPTION <br />IVSiT APPLICAT <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 6 AM TO 4 PM <br />BLOCK <br />NO. I TYPE OP FIXTURE OR ITEM <br />Tollet <br />Bathtub <br />Lavatory (wash basin) <br />Shower <br />Kitchen sink 8 disposal <br />Dishwashar <br />Clolhes washer <br />Water heater <br />Sink (servlcelbarlmop/elc.) <br />Backflow preventer <br />Urinal <br />Drinking Fountafn <br />Floor draln <br />Grease trep <br />Roof drains <br />Other <br />PARCEL TAX I D. A� <br />TRACT <br />ICONTACT FOR PERMIT <br />ADDRESS <br />- - CITY2IP PAONE —' <br />HEATSOURCE <br />_ Electric _ Gas _ Other <br />PHONE <br />CITY2IP PHONE <br />I CONTRACT PRICE OF WGRK <br />NO. I TYPE OF fIXTURE OR ITEM <br />A/C - air handlirp units <br />Forced eir systema <br />Gas piping <br />Water heater <br />Gas flreplace <br />Ges ranpe <br />Clothes dryer <br />Range hood <br />E#�eust fan <br />Heal pump <br />Unit heater <br />Boiler <br />Refriperadon <br />Woodstove <br />Other <br />CITY OF EVERETT LOCAL SALES TAX CODE IS ]105 <br />I hereby ceritify that I have read and ezamined thfs application and know the same to be We a�d cortoct. All provlabns of lews and <br />ordinaces goveming this rype of work will be camplied with whether speGfiad hereln or rat. The gran8ng oi e permft does not presume <br />to gfve authority to violate or cancel the provis(on of any other state or local law regulatirp consfrudion or fhe performance ot <br />construcUon. That I am authorized by the owner of this property to pe�fortn lhe work for which epplicetlon fs made and I comply with the <br />Slate Contractors Law 18.27 RCW and 296.200 WAC. <br />Signature of Owner/ContractorlAuthorized Agent Date <br />