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PERMIT APPLICATIOf� <br /> BUILDINC�CHANICAL/ PLUMBING /SIGN ' —RINKLER/ 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 <br /> Biue�r�la�k�nkr���l'�eas� " �" �.�_��:�.��E>C��S�� w�l���.��.e ::�� �z "����-�� -�-'�-�.�� ��.���`�-�: <br /> PROJECT SITE ADDRESS: 9OO W CaS1110 RD �� PROPERTY TAX#: 003g21-000-004-01 <br /> LEGAL for new construction: Short PlaUsubdivision Lot No. (attach copy of long legal description) <br /> ff ^�� r �� '', �� 'ff���`��^ �r:y�.� � � ��z� �u 3�2�x �`�v§ u r �� z �::s�:s - �k��3,^tt �., z� <br /> �� � �4�� � ��b °�� �' ��- �� °�' �:;CONTA�'�'��1� �'�I�N<� `x�` �;����;� �:����°�� �.���� <br /> "' ,,.v:p.� �-..,� .�.. .,� ., .... . ._.. a ��.. . ,4�.' f.�..F ,� .,�. <br /> .:�h,..r r�i�a,.,nh-w.. 1� c y.r�K�....,K.9.��' ..-�:,F.,:..,. <br /> OWNER NAME: Pat'kSICI@ AC uisition Preservation TENANT NAME(If Commercial): <br /> OWNER MAILING ADDRESS: srRee-r 21515 Hawthorne BLVD STE 395 <br /> �� Torrance STp`TE CA Z�P 90503 <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR NAME: H011llb@C �'i0. <br /> CONTRACTOR ADDRESS: sTaEeT 1128 8th St E <br /> ��TM Kirkland sTATE WA Z�P 98033 <br /> CONTRACTOR PHONE: 42'rJHZZZ23S CONTRACTOR EMAIL: aJaCOIJK@IlOII11I�2t'gCO.COCTI <br /> CONTRACTOR LICENSE#(REQUIRED): HOLMBC*066ME CITYOF EVERETT BUSINESS LICENSE#(REQUIRED): OrJ1 003 <br /> PRIMARY CONTACT: ❑OWNER �CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: <br /> CONTACT EMAIL: <br /> ��� ���x �� � � �� � -� ����. <br /> -�. � & �, ����,�,-� �����`"��'1�1N���ER�Ii�' ����� ��,�.-�F�'��,�'�''��� `�` - .5.� <br /> � .� .�_�„�� <br /> �t � _ �� � <br /> �� �fr.�„�.� ��. <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 : <br /> ` :� ��M�c'��►����'��.��i �;,�.�+�c►�r-��r� � K�-�.��B��aii���`�t!��" �t��:�"�Qa���� � _ - <br /> � �� ,. � ., �, � <br /> = __ . � .. �. �.�. _.F __ . . . . :�. � y- ��- v_, -- . ..,,�r .�. <br /> . � , <br /> � ,.. .r .. � f , .a <br /> Type of Project: _New Addn Alteration _Repair Type of Project: _New Addn Alteration _Repair <br /> #of ��st of FixEures #of List of Fixtures #of �ist of Fixtures #of List of Fixtures <br /> Fixtures Fixtures Fixtwes Fixtures <br /> A/C—Air Handling Units Heat Pump t� 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 4 Sink(Seroice/BadMop/etc. Other: <br /> � <:�,.����.�..�����.�'���.� �����1'�� � <br /> Chemical or Water 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.1 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 Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett O�cia/Use Only <br /> PERMIT#/�I���� D L � <br /> Y 0 <br /> Owner/Authorized Agent Signature Date (Revised 9/23/2016) <br />