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PERMIT 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 /> +jBjju� l k I .Qn1Y P1 Se ` © - SITE. ^FORMA "1©W <br /> PROJECT SITE ADDRESS: -42-0 Rue.X 0( )4V'e - PROPERTY TAX#: <br /> LEGAL for new construction: Short Plat/subdivision Lot No. (attach copy of long legal description) <br /> \ � a <br /> IVfT�1�T 11�IFRMI# .�., 4 <br /> OWNER NAME: CiOm ,(,{nt4- (44,-eaR -. O/Q,¢/\tieX' TENANT NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET �V`i�� f'i�) W - <br /> CITY eAp-ejkre:!° STATE \/ ., ZIP �-F/O <br /> OWNER PHONE:'+g-5j- �b ` �j7QQ OWNER EMAIL: 4��(%�( �°il�(tl�A' r1 e.,*( )O. <br /> CONTRACTOR NAME: 1A T)(A Zt6t&f/1 <br /> CONTRACTOR ADDRESS: STREET 155-1/1—) 1Lp' AVP, \Afe 30-14-r-_ J <br /> CITY d'�/yv It \ V STATE1 IJV'/7` `,� (,,ZIIP q�jt/- / <br /> CONTRACTOR PHONE: " S— q(.Q''(- 0400 CONTRA R EMAIL: W'l 1`P IA 0),vVU�Id t��°C011) <br /> CONTRACTOR LICENSE#(REQUIRED) (.)TZQVJ I S2.QZ.N\ CITY OF EVERETT BUSINESS LICENSE#(REQUIRED) 41)1 <br /> PRIMARY CONTACT: 0 OWNER 'CONTRACTOR 0 OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: .s- q(y`1- P>OQ <br /> CONTACT EMAIL: imaU-CC AA if exov1/4-e"o{ik o i ovY1 <br /> �t ��l L DING RMIT ►s ... C� <br /> .)<,.y -..,/� �� env. _ .. ..o. r � _. .. .. „ ,'^vr�.+e�l�F"''L �, ,•rqK .. <br /> Existing Use of Building: _ _ - Contract Pric f Work:$ _� V®C <br /> I T <br /> Proposed Use of Building: l�� (oak (j in( (V Heat Source: EI <br /> lectric ❑Ot <br /> Building Type: ❑SFR-Detached ❑SFR-Attached ❑Duplex ❑Multi-Family-#of Units: Commercial '❑Industrial <br /> Type of Project: ❑New ❑Addition ❑Remodel ❑Repair 'T.I. ❑Sign ❑Sprinkler ❑Demolition ❑Change of Use <br /> DESCRIPTION OF WORK: , <br /> -Yo --C)C+'X(©( t,c l G�t�1Gt tC S <br /> ASSOCIATED BUILDING PERMIT#(if applicable): <br /> 1Afili OStit t1'1`.a ttif011I0N „....«a... PLUMB Nl PERMIT*W*4*10 i <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 /> */#01 LER k ,' ". ION:SYsre '/ <br /> Chemical or Water I No.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 gr• ting 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 un.-r any circumstance.lam 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 Contractors La 18.27 RCW and 296.200A WAC. <br /> 41(tibLe-"IR <br /> City of Everett Official Use Only <br /> � J Ir V`-'gI-z- �o lr7Owner/Authgent Signature Date (Revised 9/23/2016) <br />