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PERMIT APPLICATIO
<br /> BUILDING ECHANICAL/PLUMBING /SIGN�INKLER/ DEMOLITION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET,EVERETT,WA 98201
<br /> (P)425-257-8810 � FAX 425-257-8857 �(E}everetteps@everettwa.gov� www.everettwa.gov/permits
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<br /> PROJECT SITE ADDRESS: 9OO W CaSlt10 RD PROPERTY TAX#: 0039Z1-OOO-004-01
<br /> LEGAL for new construction: Short PlaUsubdivision Lot No. (attach copy of long legal description)
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<br /> OWNER NAME: PaCkSICI@ AC uisition Preservation TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: s�xe� 21515 Hawthorne BLVD STE 395
<br /> �� Torrance STATE CA Z�P 90503
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME: HOICYI`J@f �i0.
<br /> CONTRACTOR ADDRESS: s�ueET 1128 8th St E
<br /> ��n Kirkland STATE WA Z�P 98033
<br /> CONTRACTOR PHONE: 4Z'rJH`L2ZZ3S CONTRACTOR EMAIL: .J1C0`JK@Il0If1'lIJ@CgCO.COtII
<br /> CONTRACTOR LICENSE#(REQUIRED): HOLMBC*OGGME CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): O�J1 003
<br /> PRIMARY CONTACT: ❑OWNER �CONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE:
<br /> CONTACT EMAIL:
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<br /> Existing Use of Building: Contract Price of Work:$
<br /> Proposed Use of Building: Heat Source: ❑Gas ❑Electric ❑Other
<br /> Building Type: ❑SFR-Detached ❑SFR-Attached ❑Du lex ❑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 /> Replacing Fixtures Like for Like with no Modification
<br /> to Rough in.
<br /> ASSOCIATED BUILDING PERMIT# if applicable :
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<br /> Type of Project: _New Addn Alteration _Repair Type of Project: _New _Addn Alteration _Repair
<br /> #of List of Fixtures #of ��st of Fixtures #of List of Fixtures #of Lisf of Fixtures
<br /> Fixtures Fixtures Fixtures Fi�ctures
<br /> A/C—Air Handling Units Heat Pump Toilet Backflow Preventer(Inside Bldg)
<br /> Forced Air Systems Unit Heater Bathtub Urinat
<br /> Gas Piping Boiler 4 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 4 Sink(Service/Bar/Mop/etc.) Other:
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<br /> Chemical or Water No.of Heads
<br /> ACKNOWLEDGEMENT:1 have revie.wed this application and con�rm 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 permif only authorizes approved work and no deviations therefrom.Deviations must�rst be authorized in writing from the
<br /> Building Officia/before being authorized under any circumstance.1 am the owner,or 1 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 O�cia/Use Only
<br /> PERMIT�I �
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<br /> Owner/Authorized Agent Signature Date (Revised 9/23/2016)
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