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PERMIT APPLICATIOI�
<br /> BUILDIN�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
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<br /> PROJECT SITE ADDRESS: 9OO W CaSlf10 RD �� PROPERTY TAX#: 003921-000-004-01
<br /> LEGAL for new construction: Short PlaUsubdivision Lot No. (attach copy of long legal description)
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<br /> OWNER NAME: PaCkSICr@ AC uisition Preservation TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: sTaEer 21515 Hawthorne BLVD STE 395
<br /> ��TM Torrance STATE CA Z�P 90503
<br /> OWNER PHONE: OWNER EMAIL:
<br /> � _. ._.__. � _.__ _. ._. . __> , ,, __. .. _.... ..,.
<br /> CONTRACTOR NAME: HOIC1lIJ@C CiO.
<br /> CONTRACTOR ADDRESS: srneer 1128 8th St E
<br /> ��n Kirkland STATE WA Z�P 98033
<br /> CONTRACTOR PHONE: 4Z'Jr$2ZZ233 CONTRACTOR EMAIL: �aCOIJK(�X Il0It11IJ@I'gCO.00111
<br /> CONTRACTOR LICENSE#(REQUIRED): HOLMBC*066ME CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): O�J1 OCI3
<br /> PRIMARY CONTACT: ❑OWNER �CONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE:
<br /> CONTACT EMAIL:
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<br /> Existing Use of Building: Contract Price of Work:$
<br /> Proposed Use of Building: Heat Source: ❑Gas ❑Electric ❑Other
<br /> Building Type: ❑SFR-Detached ❑SFR-Attached ❑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 /> Replacing Fixtures Like for Like with no Modification
<br /> to Rough in.
<br /> ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> ��`�`��I�FC�I�1�1�GAi�P�R�.�1�������4������ `��`.��,X_� �PL�I1HIBi1+IG4'Pi.�E�M!'�'z�•,.���,���►���� f_�:._�¢��..`;
<br /> Type of Project: _New Addn _Alteration _Repair Type of Project: _New Addn _Alteration _Repair
<br /> #of List of Fi�rtures #of List of Fi�ctures #of List of Fixtures #of ��st of Fixfures
<br /> Fixtures Fixfures 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 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:
<br /> �" ,���!il(L�ER/��iP�RyES���AI����'���:.��-W
<br /> Chemical or Water No.of Heads
<br /> ACKNOWLEDGEMENT:1 have reviewed this application and confirm the information contained herein is true and correct.Work done pursuant to this permit must comply wifh
<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 O�cia/before being authorized under any circumstance.I am the owner,or I am authorized by the owner of this property to perform the work for which application is made,
<br /> and 1 comply with the State Contractors Law 18.27 RCW and 296.200A WAC.
<br /> City of Evereft O�cial Use Only
<br /> PER, ���n�D�
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<br /> Owner/Authorized Agent Signature Date (Revised 9/23/2016)
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