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PERMIT APPLICATIOI�I
<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 CaSltlO RD � PROPERTY TAX#: 00392�-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: PaCkSICIe AC uisition Preservation TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: sTaeeT 21515 Hawthorne BLVD STE 395
<br /> ��TM Torrance STA,� CA Z�P 90503
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME: HOIf71IJ@f �i0.
<br /> CONTRACTOR ADDRESS: s�eeT 1128 8th St E
<br /> ��n Kirkland STATE WA Z�P 98033
<br /> CONTRACTOR PHONE: 4ZJrHZZZZ33 CONTRACTOR EMAIL: JacobK@holmbergco.00111
<br /> CONTRACTOR LICENSE#(REQUIRED): HOLMBC*066ME CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): O�J1 003
<br /> PRIMARY CONTACT: ❑OWNER �CONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACTNAME: CONTACT PHONE:
<br /> CONTACT EMAIL:
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<br /> Existing Use of Building: Contract Price of Work:$
<br /> Pro sed Use of Building: Heat Source: ❑Gas ❑Electric ❑Other
<br /> Building T e: ❑SFR-Detached ❑SFR-Attached ❑Du lex ❑Multi-Family-#of Units: �Commercial ❑Industrial
<br /> Type of Pro'ect: ❑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 a plicable :
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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 �ist of Fixtures #°f List of Fixtures #°f List of Fixtures
<br /> Fixtures Fixtures Fi�ctures Fixtures
<br /> A/C—Air Handlin Units Heat Pump Toilet Backflow Preventer(Inside Bldg)
<br /> Forced Air S stems 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 /> Ran e Hood Water Heater Other:
<br /> Exhaust Fan t� Sink(Service/BaNMop/etc.) Other:
<br /> F�,����R1�1�1��R��,TT��-Rf$S'I,�DI� S�Y$��M�"�-�'
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<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 comp/y with
<br /> current federal,state,and local law.The granting of a permit only authorizes approved work and no deviafions therefrom.Deviations must�rst be authorized in writing from the
<br /> Building O�cial before being authorized under any circumstance.1 am the owner,or 1 am authorized by the owner of this properfy to perform ihe 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 Everetf O�cial Use Only
<br /> PERM #¢�O� �
<br /> (. 1
<br /> Owner/Authorized Agent Signature Date (Revised 9/23/2016)
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