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i S _ _ <br /> PERMIT APPLICATION <br /> BUILDING I MECHANICAL I PLUMBING I SIGN /SPRINKLER / DEMOLITION <br /> CITY OF EVERETT PERMIT-SERVICES <br /> 3200 CEDAR STREET, EVERETT,WA 98201 <br /> (P)425-257-8810 1 FAX 425-257-8857 i(E)everettepsgeverettwa.gov vAvw,evere1VM,goviperm;ts <br /> !(Blue ;r Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: iooi V., Q8, A-IC'3 PROPERTY TAX <br /> LEGAL for rew construction: $her',Platisubrivision Lot No <br /> (attach copy cf long iega'descr pfi on <br /> CONTACT INFORMATION <br /> OWNER NAME: 'llx-e-1 Denyn ' TENANT NAME(If Commercial): <br /> OWNER MAILING ADDRESS: r) L <br /> i n n�I \Ai CIA vi V A- 103 <br /> c'1TY '7- 1(S'V& Z,7ATE WA zip <br /> OWNER PHONE: 7 �'J 64 qk-2 <br /> f-L JOWNER EMAIL. <br /> CONTRACTOR NAME ri 1, <br /> CONTRACTOR ADDRESS; STREET 14 0 '1 <br /> V <br /> crry S T",TE 7 <br /> CONTRACTOR PHONE: 2- CONTRACTOR EMAIL: <br /> n L <br /> CONTRACTOR LICENSE#(REQUIRED;: JCI;Y OF EVERETT BUSINESS LICENSE#(REQUIRED):�5 <br /> PRIMARY CONTACT: DOWNER 2"CONTRACTOR El OTHER{Please Specify)_ <br /> CONTACT NAME: 7( CONTACT PHONE: <br /> CONTACT EMAIL: <br /> BUILDING PERMIT APPLICATION <br /> ,'Existing Use of Building, CotTtract Price of Work: <br /> Proposed Use of Building: lHeat Source: E]Gas ElEiectric: 110ther <br /> Building Type: 03FIR-Detached OSFR-Attached OlDuplex EJMulti-Family-#of Units: ClCornmerciai Cindustrial <br /> Type of Project: ONew CDAddition CIRemodel ®Repair CITI. -..[]Sig;i OSprinkler DDerncl;-tion EIC-hangeofUse <br /> DESCRIPTION OF WORK: .......... <br /> i(q.VtC(- W kkY JUA� <br /> LASSOCIATED BUILDING PERMIT# "if applicable)� <br /> MECHANICAL PERMIT APPLICATION PLUMBING PERMIT APPLICATION <br /> Type of Project: —New — Addn —Alteration _Repair Type of Project: _New Addin _-Alteration 'Repair <br /> #of #of #of #of <br /> Fixtures List of Fixtures Fixtures List of Fixtures Li <br /> Fixtures st of Fixtures Fixtures List of Fixtures <br /> I A/C-Air Handling Units Heat Pump Toilet Backflow Preventer(inside Bldg, <br /> I Forced Air Systerns Unit Heater Bathtub Urinal <br /> -Gas Piping Boiler Lavatory(Wash Basin) Drinking Fountain <br /> Water Heater Refrigeration Shower Floor Drain <br /> _JGas Fireplace 'Nood 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 Farr Sink(Service/Bar,,Mopietc) Other: <br /> SPRINKLER/SUPPRESSION SYSTEM <br /> =Number of Heads <br /> A CKNOWLEDGEMENT i have reviewed nils application and confirm the information conte'recYherein is true and correct. Work done oursuant to this permit must comply with <br /> current federai,slate,and local law. The grarling Of a PerrnI cn,'Y authorizes approved work and no deviations therefrom.Daviations must first be authorized in writing from the <br /> Sodding official telore Deing authorized under any circumstance, I am the owner,o,I am authorized by the owner of this property to perform the work for which application is made, <br /> and i comply vvith the State Contractors Lora 16,27 ROVI-and 296,200A'VAC, <br /> City of Everett offic;a;Use aniy <br /> PER) <br /> T �� <br /> Owner/Authorized Agent Signature <br /> Date (Revised 51220,12016) <br />