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PERMIT APPLICATION
<br /> BUILDING/MECHANICAL/PLUMBING/SIGN/SPRINKLER/DEMOLITION
<br /> GTY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET,EVERETT,WA 98201
<br /> (P)425-257-8810 � FAX 425-257-8857 �(E)everetteps@evereriwa.gov� www.everetiwa.gov/permits
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<br /> PROJECT SITE ADDRESS: Q�'�� ��'� , S PROPERTY TAX#: �"�Q�ps�
<br /> LEGAL for new construction: Short PlaUsubdivision Lot No. (attach copy of long legal description)
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<br /> OWNER NAME: �� ? �� �� TENANT NAME(If Commercial): �
<br /> OWNER MAIUNG ApDR S: s�er J �� rj�
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<br /> OWNER PHONE: - OWNER EMAIL:
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<br /> CONTRACTOR NAME; � �(_,_
<br /> CONTRACTOR ADDRESS: srixeer � ��-tJ rSU i t�, �
<br /> CITY STATE , A"� ZIP��Q�
<br /> CONTRACTOR PHONE: �-S( CONTRACTOR EMAIL: � �Cp�Q(Q� � S�, 'rl •
<br /> CONTRACTOR LICENSE#{REQUIRED): GJ �� � CITY aF EVERETT BUSINESS LICEN �REQUIRE : �}�b
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<br /> PRIMARY CONTAGT: �OWNER ❑CONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: �-����
<br /> ��� ����� CONTACT EMAIL:
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<br /> Existin Use of Buildin : Contract Price of Work:$ 5
<br /> Pro osed Use of Buildin : Heat Source: Gas Electric ❑Other
<br /> Buiiding Type: ❑SFR-Detached SFR-Attached ❑Duplex �Multi-Famil -#of Units: Commercial ❑Industrial
<br /> T e of Pro'ect: ❑New DAddition ❑Remodel ❑Re air OT.I. ❑Sign ❑Sprinkler ❑Demolition ❑Chan e of Use
<br /> DESCRIPTION OF WORK: (� ('�
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<br /> ASSOCIATED BUILDING PERMIT# if a licable :
<br /> � M�CHi�'NI��L;PE1i�1"t'API�L��ATMb1+1 ,.'; �L�M�1���:P�RN1{T�PP41��'"'C�#�N .;, . , .�. '
<br /> Type of Project: _New Addn _Alteration�Repair Type of Project: _New _Addn _Alteration _Repair
<br /> #of �/st of Fixtures #�f List of Fi�ctures #of List of Fixtures #of /�st of FP�ures
<br /> Fbctures Fixtures Fixtures Fl�ctures
<br /> A1C-Air Handlin Units Heat Pump Toilet Backflow Preventer Inside Bid
<br /> 1 Forced Air Systems Unit Heater Bathtub Urinai
<br /> Gas Pipin Boiler Lavato (Wash Basin Drinking Fountain
<br /> Water Heater Refri eration Shower Floor Drain
<br /> Gas Fire lace Wood Stove Kitchen Sink&Disposal Grease Trap
<br /> Gas Ran e Ductin Dishwasher Roof Drains
<br /> Clothes D er Hookups Other: Clothes Washer Medical Gas
<br /> Ran e Hood Water Heater Other:
<br /> Exhaust Fan Sink ServicetBar/Mo /etc.) Other;
<br /> <.,�: , ., �i�"t�t�IK#.��i�/';�U�!��$���?��,�'�i!'�'�'E�� ; .,..;
<br /> Chemical or Water No.of Heads
<br /> ACKNOWLEDGEMENT.•I have reviewed this application and confmr the info�nation 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 permlt on/y authorizes approved work and no deviadons therefrom.Deviatlons must flirst be authorized ln wiiting from the
<br /> Building Official before being authorized under any circumstance./am the owner,or 1 am authorized by the owner of this property to perform the work for which application is made,
<br /> and 1 comp/ with th te Con t Law 98. RC and .200A WAC.
<br /> City of Everett Official Use Only
<br /> ��1� 1�- pE ��-� � - ��
<br /> Ow e ut ed e igna Date (Revised 9/23/2016)
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