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PERMIT APPLICATIOIjC <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 1(E)everetteps@everettwa.gov 1 www.everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: 1324 100th PL SE PROPERTY TAX#: <br /> LEGAL for new construction: Short Plat/subdivision Lot No. (attach copy of long legal description) <br /> CONTACT INFORMATION <br /> OWNER NAME: Country Club Preservation LP TENANT NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET 21515 Hawthorne BLVD STE 125 <br /> CITY Torrance STATE CA ZIP 90503 <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR NAME: Holmberg Co. <br /> CONTRACTOR ADDRESS: STREET 15400 SE 30th Place, Suite 100 <br /> cnY Bellevue STATE WA ZIP 98007 <br /> CONTRACTOR PHONE: 4256027370 CONTRACTOR EMAIL: Jacobk@holmbergco.com <br /> CONTRACTOR LICENSE#(REQUIRED): H Imbc*066ME CITY OF EVERETT BUSINESS LICENSE#(REQUIRED):051003 <br /> PRIMARY CONTACT: 0 OWNER CONTRACTOR 0 OTHER(Please Specify) <br /> CONTACT NAME: Jacob Klein CONTACT PHONE: 4256027370 <br /> CONTACT EMAIL: Jacobk@holmbergco.com <br /> BUILDING PERMIT APPLICATION <br /> Existing Use of Building: Contract Price of Work:$ 4200 <br /> Proposed Use of Building: eat Source: CI Gas CI Electric ❑Other <br /> Building Type: ❑SFR-Detached ❑SFached ❑Duplex ulti-Family-#of Units: CI Commercial CI Industrial <br /> Type of Project: ❑New ❑Addition emodel ❑Repair CIT.!. ❑Sign ❑Sprinkler CI Demolition ❑Change of Use <br /> DESCRIPTION OF WORK:r 6A k PA�� `x { (11^ <br /> GThc`IC— n <br /> ASSOCIATED BUILDING PERMIT#(if applicable): <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 /> NC—Air Handling Units Heat Pump l Toilet Backflow Preventer(Inside Bldg) <br /> Forced Air Systems Unit Heater t a Bathtub Urinal <br /> Gas Piping Boiler \a Lavatory(Wash Basin) Drinking Fountain <br /> Water Heater Refrigeration Shower Floor Drain <br /> Gas Fireplace Wood Stove VA, Kitchen Sink&Disposal Grease Trap <br /> Gas Range Ducting Dishwasher Roof Drains <br /> Clothes Dryer Hookups Other: Clothes Washer Medical Gas <br /> Range Hood `a Water Heater 3Other: BS <br /> `"e, Exhaust Fan Sink(Service/Bar/Mop/etc.) Other. <br /> SPRINKLER I SUPPRESSION SYSTEM <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 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.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 Law 18.27 RCW and 296.200A WAC. <br /> / / City of Everett Official Use Only <br /> ( <br /> �j (O/;(1 ( PERMIT# D 7 — /r <br /> • !"er/Authorized Agent Signature Date (i?evised 9/23/2016) <br />