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PERMIT APPLICATION
<br /> BUILDING/MECHANICAL/PLUMBING/SIGN/SPRINKLER/DEMOLITION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET,EVERETT,WA 98201
<br /> (P)425-257-8810 � FAX 425-257-8857 �(Ej everetteps@evereriwa.gov� www.evereriwa.gov/permits
<br /> (Biue or B/ack/nk.On�y P/ease),, ,"._ =PR0.IECT S%TE�NF-ORIG�A�JDN>. ,_ , -
<br /> PROJECT SITE ADDRESS: W PROPERTY TAX#:
<br /> LEGAL for new construction: Short Plat/subdivision Lot No. (attach copy of long legal description)
<br /> - CONT�44�':1NFORN�I'�iT10N� `
<br /> OWNER NAME: �� �TENANT NAME(If Commercial):� � � � �j
<br /> OWNER MAILING ADDRESS: sTaEer ��� �( �Z
<br /> aTv srn� � ziP �2,Z
<br /> OWNER PHONE: y�– �g� � OWNER EMAIL: C �rj
<br /> __.. _ _,. _ ___ _, __. __ . _.._..._ .. _. .
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<br /> CONTRACTOR NAME:
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<br /> CONTRACTOR ADDRESS: s-rRee-r — A
<br /> CfTY STATE ZIP � ' �
<br /> CONTRACTOR PHONE: (�' SlQ2�a�/ CONTRACTOR EMAIL: �
<br /> CONTRACTOR LICENSE#(REQUIRED): CITY OF EVERETT BUSINESS LICENSE#(REQUIRED):
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<br /> PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR OTHER(Please Specify) �
<br /> CONTACT NAME: �r'�G�� ���Q� CONTACT PHONE: t5—a,G1 L�- v
<br /> M, �' i� CONTACT EMAIL: o /�Q,r'1LQ�Y (1(�� M Q.Y'Cl/�• C'•OI�1(�
<br /> ;• -� - ,`- �s ,. - �� �I/1 �p �'' ��"x��.r�'�' s'�,� s� S n a "" J� t���' "-�'F',.K�
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<br /> Existing Use of Building: � Contract Price of Work:$ ---
<br /> Proposed Use of Building: l� Y" Heat Source: Gas ❑Electric OOther
<br /> Building Type: ❑SFR-Detached ❑SFR-Attached ❑Duplex ❑Multi-Famil -#of Units: Commercial ❑Industrial
<br /> Type of Project: ❑New ❑Addition Remodel ❑Repair OT.I. ❑Sign ❑Sprinkler ❑Demolition ❑Change of Use
<br /> DESCRIPTION OF WORK: I„��,�j Dr r.�1'W�p ` '��CI u,J�n Ln�S1„n� /� ,���+�� �
<br /> ��!U lJ� 4 (.�1, V� � l,�i�17L�(��
<br /> �1�t-lo �O,rin ;nte,riv� �-��on��
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<br /> ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> � �'rEc��,���������ii���������►��u� �4� .t�i �����'"��,..,;�;�►���',.��������V► �...,���.��_���
<br /> ��,
<br /> Type of Project: New Addn AReration _Repair Type of Project: New Addn Alteration _Repair
<br /> #of List of Fixtures #of List of Fixtures #�f tist of Fixtuies #of List of Fixtures
<br /> Fixtures Fixtures Fixtures Fixtuies
<br /> AIC–Air Handlin Units Heat Pump Toilet Backflow Preventer Inside Bidg
<br /> Forced Air Systems Unit Heater Bathtub Urinal
<br /> Gas Piping Boiler Lavatory(Wash Basin) Drinking Fountain
<br /> Water Heater Reftigeration 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 /> `� SPR/NKt.L�R 15UPiPYtE,SSlOi11;SY�'l"EM
<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 permft must comp/y with
<br /> current federal,state,and local law.The granting of a permit on/y authorizes approved work and no deviatio»s therefrom.Deviations must first be authorized in writing from the
<br /> Building O�cial before being authorized under any circumstance.I am the owner,or I am authorized by the owner of this property to perform the work for which application is made,
<br /> d I comply wit e State Conf ctors Law 18.27 RCW and 296.200A WAC.
<br /> City of Everett O�cia/Use On/y
<br /> � D"�J I� PE� \ 1v� ` V� ,--y _ ..
<br /> Owner thorized Agent � Date (Revised 9/23/2016) ,,�' . ';
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