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grrPERMIT APPLICATION
<br /> BUILDING / MECHANICAL/ PLUMBING /SIGN /SPRINKLER/ DEMOLITION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET,EVERETT,WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov I www.everettwa.gov/permits
<br /> PROJECT SITE INFORMATION
<br /> PROJECT SITE ADDRESS. PROPERTY TAX#:
<br /> 1 z'i o 2- - i `t*.ti Av SE,EV-err tt 1$Zct 2 "3 Z 7-0 2
<br /> LEGAL for new construction: Short Plat/subdivision Lot No. (attach copy of long legal description)
<br /> CONTACT INFORMATION
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<br /> OWNER NAME: Lem NI vi_m w�E:S! bt /TENANT NAME(If Commercial): ORA NHIC HFOgY i!-1 TITt:SS
<br /> OWNER MAILING ADDRESS:ely STREET 5, A.--T �
<br /> K„iw, „,J, Lie '767 [I6 r -Al LASE J)2,�E, l\I,
<br /> Fr CITY SEA 1 r L E STATE WA ZIP q e/o3
<br /> OWNER PHONE: Zc:C-, --706...,- - Z(..,'-c, OWNER
<br /> `EMAIL: s7T e Se_G"nH
<br /> - A vM p,s M
<br /> i . Goi
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<br /> CONTRACTOR NAME: JCX pgEss C,4 ".1y i r2litt T1 0 4\1 .Z,JG
<br /> CONTRACTOR ADDRESS: STREET ;1;5 - 1/ S 4'4- ,4 SC , STE- /00
<br /> CITY &L LE V(4 e STATE IAA ZIP 9 0 j NI
<br /> t:PHONE: 2��-2 30 --5 CONTRACTOR EMAIL: ,' �1:� (I 5a/J( P(E s.Cur!sfp.ticil it , IVE 1
<br /> CONTRACTOR LICENSE#(REQUIRED): ( x PeECCOtO E.,
<br /> I—.i_ CITY OF EVERETT BUSINESS LICENSE#(REQUIRED):C'-/SCIS C_,
<br /> PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR tprOTHER(Please Specify) C.OIJST/Quc nc 1 MA-A.1460Q
<br /> CONTACT NAME: CONTACT PHONE: 20k, (U ..._2__L, 3,;
<br /> , c7c-,T i A ' (-(v M(SFvJ CONTACT EMAIL:,S,,,.n-67' c - - -T C,t,(pSa;`j [o,4,(
<br /> BUILDING PERMIT APPLICATION }�
<br /> Existing Use of Building: ]4-ti -G. E Tl/t,i) i 0 Contract Price of Work: $ 71 31) 1 " 2C"', K.
<br /> Proposed Use of Building: -moi T,sJl 55 S),cot o Heat Source: , Gas ❑Electric ❑Other
<br /> Building Type: ❑SFR-Detached ❑SFR-Attached ❑Duplex ❑Multi-Family-#of Units: gCommercial ❑Industrial
<br /> Type of Project: ONew ❑Addition ❑Remodel ❑Repair ❑T.I. ❑Sign ❑Sprinkler gemolition ❑Change of Use
<br /> DESCRIPTION OF WORK: 1.10,../- j R 4C-r-LA Pitt— DEAAt)L— ,.T i'i\.) /N.)
<br /> per✓-pA-2r47 1 o Ni L-,--F - : ,
<br /> ASSOCIATED BUILDING PERMIT#(if applicable): ]((GO 3 -O GS
<br /> MECHANICAL PERMIT APPLICATION PLUMBING PERMIT APPLICATION
<br /> Type of Project: New _ Addn Alteration _Repair Type of Project: _New _Addn _Alteration _Repair
<br /> #of List of Fixtures #of List of Fixtures #of List of Fixtures #of List of Fixtures
<br /> Fixtures Fixtures Fixtures Fixtures
<br /> A/C-Air Handling Units Heat Pump Toilet Backflow Preventer(Inside Bldg)
<br /> Forced Air Systems Unit Heater Bathtub Urinal
<br /> Gas Piping Boiler Lavatory(Wash Basin) Drinking Fountain
<br /> Water Heater Refrigeration Shower Floor Drain
<br /> Gas Fireplace Wood Stove Kitchen Sink&Disposal Grease Trap
<br /> Gas Range Ducting Dishwasher Roof Drains
<br /> Clothes Dryer Hookups Other: Clothes Washer Medical Gas
<br /> Range Hood Water Heater Other:
<br /> Exhaust Fan Sink(Service/Bar/Mop/etc.) Other:
<br /> SPRINKLER/ SUPPRESSION SYSTEM
<br /> Number of Heads
<br /> ACKNOWLEDGEMENT:I have reviewed this application and confirm the information contained herein is true and correct. Work done pursuant to this permit must comply with
<br /> current federal,state,and local law. The granting of a permit only authorizes approved work and no deviations therefrom.Deviations must first be authorized in writing from the
<br /> Building Official before being authorized under any circumstance.I am the owner,or I am authorized by the owner of this property to perform the work for which application is made,
<br /> and I comply with the State ontractors Law 18.27 RCW and 296.200A WAC.
<br /> City of Everett Official Use Only
<br /> l PERMIT#..--
<br /> er/Authorized Agent g---nature ate (Revised 10/12/2015)
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