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PERMIT APPLICATION
<br /> BUILDING/MECHANICAL/PLUMBING /SIGN/SPRINKLER/DEMOLITION
<br /> CITY OF EVERETT PERMIT SERVICES �R1 G 1 NAL
<br /> 3200 CEDAR STREET,EVEREIT,WA 98201 �z
<br /> (P)425-257-8810 � FAX 425-257-8857 �(E)everetteps@everettwa.gov� www.everettwa. permits
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<br /> � PROJECT�SITE ADDRESS��� � �� � PROPERTY TAX#: � � � �
<br /> LEGAL for new construction: Short Plat/subdivision Lot No. (attach copy of long legal description)
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<br /> OWNER NAME: TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRE S: sTReeT L�'1
<br /> CIN STATE ZIP 3
<br /> OWNER PHONE: �j17'� — OWNER EMAIL: �
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<br /> CONTRACTOR NAME;
<br /> CONTRACTOR ADDRESS: STREET �'I
<br /> CITY l, STATE ZIP
<br /> CONTRACTOR PHONE: �r � — � CONTRACTOR EMAIL: �
<br /> CONTRACTOR LICENSE#(REQUIRED): L„ � � CITY OF EVERETT BUSINESS LICENSE#(REQUIRED):
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<br /> PRIMARY CONTACT ❑OWNER �CONTRACTOR ❑OTHER(Please Specify)
<br /> CONTA T NAME: CONTACT PHONE: I. Z�— '3
<br /> �CJ1,���, � CONTACT EMAIL:i
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<br /> Existing Use of Buildin : Contract Price of Work:$
<br /> Proposed Use of Building: Heat Source: ❑Gas lectric ❑Other
<br /> Building Type: FR-Detached ❑SFR-Attached ❑Duplex ❑Multi-Family-#of Units: ❑Commercial ❑Industrial
<br /> Type of Pro'ect: ❑New ddition ❑Remodel ❑Repair ❑T.I. ❑Si n ❑S rinkler ❑Demoiition ❑Chan e of Use
<br /> DESCRIPTION OF WORK:
<br /> �C i�:�,�la�
<br /> ASSOCIATED BUILDING PERMIT# if ap licabie :
<br /> �,�%"�����,11�IECHAN�C•AL,PERMIT+APPLICATlONw�R�t�. ��_ ,��_,p..�,�a���'n;rP,LUMBING°'PERMITAPPLICATIO�1� �� ��.; �� :
<br /> � ..�-�na��-. f
<br /> Type of Project: _New Addn Alteration _Repair Type of Project: New Addn Alteration _Repair
<br /> 1 #of #of #of #of
<br /> Fixtures u�°f Fixtures Fixtures List of Fixfures Fixtures Lisf of Fixtures Fixtures List of Fixtures
<br /> A/C—Air Handlin Units Heat Pump Toilet Backflow Preventer(Inside Bidg)
<br /> ! Forced Air Systems Unit Heater Bathtub Urinal
<br /> � Gas Piping Boiler Lavato (Wash Basin) Drinking Fountain
<br /> Water Heater Refrigeration Showec Floor Drain
<br />`� Gas Fireplace Wood Stove Kitchen Sink&Disposal Grease Trap
<br /> Gas Range . Ducting Dishwasher Roof D�ains
<br /> Clothes Dryer Hookups Other. Clothes Washer Medicai Gas
<br /> Range Hood Water Heater Other:
<br /> Exhaust Fan Sink Service/Bar/Mo /etc.) Other:
<br /> "'���� SPRINICLER/{SUPPR��,SSIONs,S�1f'STEI„W�����ry
<br /> Number of�Heads
<br /> AC{WOWLEDGEMENT.•I have reviewed this application and confirm the iriformation contained herein is true and correct.Work done pursuant to this permit must compty with
<br /> current federal,state,and local 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 Official before being authorized under any circumstance.l am the owner,or I am authorized by the owner of this property to perform the work for which application is made,
<br /> and/comp/y with the State Contractors Law 18.27 RCW and 296.200A WAC.
<br /> City of Everett Official Use Only
<br /> � � � PERM,I�#� ��0�' �( �5/
<br /> Y Y I,
<br /> ner/ nt Signat e Date � (Revised 10/12/2015)
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