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I <br /> PERMIT APPLICATION <br /> BUILDING/MECHANICAL I PLUMBING /SIGN /SPRINKLER/DEMOLITION <br /> CITY OF-EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET,EYERETT,WA 98201 <br /> (P)425-257-8810 � FAX 425-257-8857 �(E)everetteps@everettwa.gov� www.evereriwa.gov/permits <br /> �Biue or Black Ink Only Piease) PROJEGT SIT� 1NFORMATION <br /> PROJECT SITE ADDRESS:910 SE Everett Mall Way,Ste D PROPERTY TAX#: <br /> LEGAL for newconstruction: Short PlaUsubdivision Lot No. (attach copy of long legal description) <br /> GONTACT INFORMATION' <br /> OWNER NAME: H&R Block TENANT NAME(If Commerciai):H&R Block <br /> OWNER MAILING ADDRESS: sTReer 575 Maryville Centre Dr.Ste 600 <br /> ciTy St.Louis srATE MO ZiP 63141 <br /> OWNER PHONE: 262.865.6101 OWNER EMAIL: <br /> CONTRACTOR NAME; Horizon Retail Construction <br /> CONTRACTOR ADDRESS: sTReeT 1500 Horizon Dr. <br /> �iiy Sturtevant srATE WI ZiP 53177 <br /> CONTRACTOR PHONE: 262:865.6101 CONTRACTOR EMAIL:lanh@horizonretail.com <br /> CONTRACTOR LICENSE#(REQUIRED):601-483-044 CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): 43526 <br /> PRIMARY CONTAGL• ❑AWNER ❑X CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: 262.865.6101 <br /> Jan Herman-Horizon Retaii Construction <br /> CONTACT EMAIL: janh@horizo taiL <br /> BUtLDING PERMIT APPLICATION <br /> Existing Use of Building: H&R Block office Contract Price of Work:$ 75,000 <br /> Proposed Use of Building: H&R Block office Heat Source: �Gas ❑ ectric ❑Other <br /> Building Type: ❑SFR-Detached ❑SFR-Attached ❑Duplex ❑Multi-Family-#of Units: ommercial ❑Industrial <br /> Type of Project: ❑New ❑Addition �Remodel ❑Repair ❑T.I. ❑Sign ❑Sprinkler ❑Demolition ❑Change of Use <br /> DESCRIPTION OF WORK: Remodel of existing H&R Block Office. ' s),demolition& <br /> installation of interior non-load bearing partitions <br /> ASSOCIATED BUILDING PERMIT# if applicable : <br /> MECHANICAI.PERMIT APPLICATION ' PLUMBING PERMIT APPLICATION <br /> Type of Project: _New Addn Alteration Repair Type of Project: _New Addn Alteration Repair <br /> #of #of #of #of <br /> List of Fixtures List of Fixtures Lisf of Fixtures Lisf of Fixtures <br /> Fixtures Fixfures Fi�ctures 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 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 Sink(Service/Bar/Mop/etc.) Other: <br /> SPRINKLER'./SUPPRESSION SYSTEM <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 comply wifh <br /> current federal,state, d local law.The granting of a permit only authorizes approved work and no deviations therefrom.Deviations must flirst be authorized in writing from the <br /> Buildi O�cia/before eing authorized under any circumstance.I am the owner,or 1 am authorized by the owner of fhis property to perform the work for which application is made, <br /> and 1 ompty with e ate Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett O�cial Use Only <br /> PERMIT# � � / � <br /> Ow er/Authorized gent Sign ure Date (Revised 9/23/2016) <br /> � � � � � � � �� <br />