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PERMIT APPLICATIO�
<br /> BUILDINOECHANICAL/ 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 �6 PROPERTY 7AX#: 003921-000-004-01 p
<br /> LEGAL for new construction: Short PlaUsubdivision Lot No. (attach copy of long legal description)
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<br /> OWNER NAME: PaCkSICIe AC UISItIOCI PC@S@PVatlOtl TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: srReET 21515 Hawthorne BLVD STE 395
<br /> ��n Torrance STATE CA Z�P 90503
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME: HOII'Tl`J@I' �'i0.
<br /> CONTRACTOR ADDRESS: sTReET 1128 8th St E
<br /> ��n Kirkland STA� WA Z�P 98033
<br /> CONTRACTOR PHONE: 4Z'JrHZZZ23S CONTRACTOR EMAIL: JaCOIJK@I101tllb@fgCO.001't'1
<br /> CONTRACTOR LICENSE#(REQUIRED): HOLMBC*066ME 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:
<br /> � ,�-�.s r } �-���,��� ���,� x��,i.� #+I�Cs��RNI1T AP���I, �'7'�DT�t" ��.��������„�}°�s'� �"
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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 /> nescR�PrioN oF woRK: Replacing Fixtures Like for Like with no Modification
<br /> to Rough in.
<br /> ASSOCIATED BUILDING PERMIT#(if applicable:
<br /> �,�="� ��IN#����1�'�►�,�n����_�'. �-��.��-��Dl!1`���. �& � ���.��P��I��i�1�'a � _��N^� �;���u-�rt�:
<br /> , _.._. _, ,. �. _. ';'} .�._ � �,
<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 Lisf of Fixtures
<br /> Fixtures FinEures 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 /> ` �`' �:�'�R�)��,��t�; �:��s._"�'_-.. ��n��N
<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/oca/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.1 am the owner,or I am authorized by fhe owner of this property to perform the work for which application is made,
<br /> and/comply with the State Contractors Law 18.27 RCW and 296.200A WAC.
<br /> City of Everetf O�cial Use Only
<br /> PERMIT#,��^ � ���
<br /> i
<br /> Owner/Authorized Agent Signature Date (Revised 9/23/2016)
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