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O1/�3/201$ WED 12: 21 FAX Fdbt WatOY HOStOY �005�012 <br /> ������a���=������ g��d�� <br /> 13W1L.Dii\IO/MECMANtC�L 1 F'LUIUl�31N�S/SIC111/SPRIML4�.�1�I l3�MOL,IT'iOld <br /> CI7Y OF EVCRE77 PERMIT SERVICEB <br /> 3200 G�[�A�t 571���T,�VERETT,WA 98201 <br /> (P)4?.8-267�8810 � FAX 423�2b7-8967 �(�)evereftepa(a��varettwe.gov� www.evar9ttwA.gov/pormlts • <br /> (��ue a►r�lacl�!nk�n� �lease PAd�J�C1P�IT�,'�l+1��R�M,t�71Ol�B <br /> pF�QJ�cr BITC A�nREss: ,� �'" PROPERTY TAX#,►. � � <br /> LEG.4�Por new canatrucllon: Short f�laf/eubdlu�elon_ _ _ _______.�,�.ot No`_„ (attaofi copy af long Iegel desorlptlan) <br /> CONTAC'P Ih1�O�tNiQT1OW <br /> OWNER NAME: TENANT NAM�(If CommerclalJ: '�`� <br /> OWNER MAILiDiO ADDRE53: arAe� V � <br /> • c�Tv �i • yra7E zm <br /> AWN�ft PHON�: OWN�R EMA!!.: <br /> CON7RAC70R NA�i�� '� S'� � '� <br /> CONTRACTOR ADDRE8S: srReEr %�'� � <br /> ' CiiY ►/ � 8TA7H YJI� ` <br /> CON'CF2A�C7QR PHON�: �a 5 CON71�AC7"pR�NlAiL: ��V�'� ►�"S �-t,� �eiY". <br /> CQNTRACTOR LECEN9E#(R�QU1R�13):� '"rj� �'}' CITY OF�VER�"T'f K3U31N�931,iCFNBE#(REquIRED) �IJ'�j <br /> PRtMARY C4N7AC7� 1] OWN�R CONTf�AC70R ❑OTI��R(I'leaso Speclfy) � <br /> GOAEl'ACT NAM�: CONT.ACT PHON�: � �/ <br /> K� ��1� �/� CONTACT gMAIl.: •.�yl/�•I-� ..��, fj(�f� <br /> BUlLD1NO PSRMI'['AP�LIGATIOIH <br /> � �Xlstln Use af Bulfdin : � " ContracE PCtc�of Work:$ � <br /> Pro os�d Use of 6ulldln : Heat Souroe: CIC�tas �leotrlc ❑Other �- <br /> �ulidln o: �3FR-Detached �S�R Attaohed ❑Du Iex G�11►uftl-Famtl -#of Units: ' CiCorr�merclel �Industrlal <br /> e of Pro ect- L�{�tew �Addltian C7Remodei fie afr CIT.l.� I�SI n �S rinkler ODemolEtlon ClChan e oP Us� <br /> DLSCRIh710N OF WOFZK: • <br /> �v�n o�� l �e,���c� ��e�-�'r i� w o���� ���o�.�-� <br /> AS$C?CI�ITED BUILDIPEG PERMI7# If e qa�ble t <br /> ' M�CM�lAhMICtiAL P�RMIT APPL.1CATfON PtilyMB11�G pllFlMIT l�►PPLICI0.TIID�1 <br /> Type oP ProJ�ct: ,�Jaw ,.,�, Addn ...,_AlEersftan _Repalr 7ype o}ProJ�ct: ,�Naw ,_._,Addn ___plteratlon �„�palr <br /> Flxtures Llsf ol Flxturss Flxtures Lla �lxfures ��f� Lfst of�lxtures Flxturea ��at of Flxfures <br /> A/C Units H tPum '�ollet 8ackflow Preventer In�fde Sld <br /> ;,. F d Alr 3 stem nlf Heater �athEub Urinal <br /> ` as Pi tn .Boiler Levato Wash"Basln Drinkln Founialn <br /> ater He�ter Retri eratlon Showsr Floor Oraln ' <br /> Gws F1re (ece Wood Slove Kl�chen S(nk&Dls oeal Grease Tra <br /> Gae Ran e u�tln nfehwasher �toof Drsins <br /> lotft0e D oku � 0 �r: Clotnea Washer Maqleai Gas <br /> d W�ter Ff�aker Ofher: <br /> �Xhflust Fen Slnlc ServlcelBar/Mo /efc. Ott16C <br /> &P�tiN �SSI� �111 <br /> emtcal or ,pr M�ads <br /> ACKIVOWL�DOEM�IVT-�I bave reWawed fhJe appqcatlar end cvnNrm tl�e/nl6rmellon conlslned here/n Is�rua aj�d camact.Wodc dana pursuent fo FAfe pam,R mvst comp�wllh <br /> eument l�deral,ste;e,and feonl lew.The a,enNnp o�e permH an(y aufiorizav eppr�oved wa,k gna no dav/allons(hwefiom.oev/aflons muat J�rsr be aulhor�ed!n wrltrnq num�rt�� <br /> BUAtl1ng OflkJe/l�IbiB beln8 evfha'hed undersny c/rcam�rt�nCa.!am the owner,or I am authodzed by fhe owner of fhls properry fo peNerm ihe warh forwRlch appllceBon►e m�dey <br /> enrf/compJy wlt�fAa 9fe(a Conlrectors Lpw 98.8T RCW and 206[YoOA WqG <br /> Clfy of 6Ver�k Of!lC/e/11�6 Only <br /> � '3 " � �� P�#1 O -O <br /> own ufhor ze Ag Signmturo Date (Revlsed 9l231�0 ) <br /> , � . <br />