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p�RMIT APPLICATI(�N <br />CITY OF EVERETT PERMIT SERVICES <br />3200 CEDAF 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 <br />SITEADDRESS L M�-k����U �I�.I� PARCELTAXI.D.p <br />zv W ��, <br />EGAL LOT NO. dIOCK TRACT OR SUBDIVISION # <br />DESC. �'Z ST� �v� OZ8 Gf <br />OWNER �. ADDRESS f <br />�};,p�,i,{ a-��c�ec.a����sa� �IZ-l`��stst. Sl.� `.y� <br />Of �= 1 <br />Or� v �o� - oa3 <br />PERMIT p <br />�. �0(�-o/Z <br />!/ZIP YI1Vfit `'}!i>i �?S'_ <br />�o�,��R aeo� Z�� <br />TEA'ANT NAME I CONTACT FOR PERMIT � PHONE ((zS 3z�-Z rySBI <br />' � �.� i µ�kQ 1.�1AQ�- . � � <br />. - � � • E-MAILYhrQ-{ �'C� l.�.b �• <br />�v9t�E �N\�-�Cv��i�C� �'a�ST �n�c.^13Z�G�uain„Illt�{c, N�u.k�l�.ea`TBz7S .�/?v 33c>9�� <br />COWTR.LI6ENSEN •� , , '. .�'�/Z� S/Z �Si <br />��/ADEML IC33DI... •� <br />USE OF Bl'ILDING <br />�-LcSc,�� c�l I<2S, c.� s� i �� <br />WORK DESCRIPTION <br />HEATSOURCE <br />_ Electric �Gas _ Olher <br />�''�i� (! �U /1.�� V � <br />NO. � TYPE OF FIXTURE OR ITEM <br />Toilel <br />Dathlub <br />Lavatory (wash basin) <br />Shower <br />Kilchen sink 8 disposal <br />Dishwasher <br />Cblhes w�shcr <br />Waler healer <br />Sink (servicc/badmop/etc.) <br />�ackflo�v prevenler <br />Urinal <br />Drinking Fountain <br />Floor drain <br />Greasc trap <br />Roo( drains <br />Other <br />CONTRACT PRICE OF WORK <br />., <br />j�� �_�� <br />�-"'/ V/ <br />%� �� <br />��3�Qrc�� <br />NO. I TYPE OF FIXTURE OR ITEM <br />A/C - air handling units <br />Forced air syslems <br />Gas piping <br />Water heater <br />Gas fireplace <br />Gas ranc�e <br />Cblhes dryer <br />Rangehood /�� ' � <br />Exhausllan � <br />Heal pump <br />Unil healer <br />Boiler <br />Refrigeration <br />Woodstove <br />Other <br />CITY OF EVERETT LOCAL SALES TAX CODE IS 3705 <br />1 hereby cerilify thal I have read and examined lhis applicalion and know the same to be lrue and correct. All provisions of laws and <br />ordinaces goveming Ihis type of work will be complied wilh whelher specified herein or not. The yrantin9 of a permit does not presume <br />lo �ive authoriry lo violate or cancel the provision o( any other slate or local law regulaling conslruction or the pedormance of <br />conslruclion. Thal I am authorized by the owner o( this property to perform the work for which applicalion is made and I comply wilh lhe <br />�Stale Con�to;,e La'• Ib.2� RCI W and 296.200 WAC. U <br />,�< c��:�' �/��'l9 <br />SignaWre of OwnedConlractor/Authori-,d Agenl Date <br />t � �� y �L� <br />