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olow <br /> 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 1 FAX 425-257-8857 I(E)everett peverettwa.gov 1 www.everettwa.govipermits <br /> (Blue or Black Ink Only Please) PROJfc t 04114$041104 <br /> a <br /> PROJECT SITE ADDRESS: 2 ma ,. PROPERTY TAX#: <br /> LEGAL for new construction: Short Plat/subdivision Lot No, (attach copy of long legal description) <br /> CONTACT INFORMATION <br /> OWNER NAME: iri- <br /> ,tv '. TENANT NAME(if Commercial <br /> OWNER MAILING ADDRESS: STREET V4,, }+t <br /> CITY.. _.. STATE....,. . ZIP920 <br /> . !:. <br /> 6 All <br /> tilkfr. <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR NAME: t . '11n <br /> CONTRACTOR ADDRESS: STREET S,,,?' ti C CLAXt <br /> CITY ..ir.. S7ATEirt.::: T_!P C.J I <br /> CONTRACTOR PHONE: ...A. e,,,,,, CONTRACTOR EMAIL: a, *.;1.. ' r'yl "l,e , ..cow <br /> CONTRACTOR LICENSE#(REQUIRED):CIYIVteCi.I11 lid"f CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): 1 <br /> PRIMARY CONTACT: 0 OWNER 10:CONTRACTOR 0 OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: <br /> CONTACT EMAIL ---l�e. cm n <br /> ci <br /> to rn <br /> '--;SUILtift00001trA#M04/10#1 <br /> Existin Use of Sufld{n Contract Price of Work; ` <br /> Proposed Use of Sulldinb: Heat Source: DEleotrlc ❑Other <br /> Buildirt 1' pe: ' FR-Detached ❑SFR-Attached ODu«les ElltittAttoParnit 4 of Units: ❑Commercial Dlndustrial <br /> Type of Project: ❑New ❑Addition ❑Remodel ❑Repair E u. CIStgn, ©Sprinkler ❑Demolition ❑Change of Use <br /> ! f <br /> 1 ns .f t(,tpi`t)9�' ,$ 1hS2.v <br /> DESCRIPTION OF WORK: '"f' <br /> 1 �'I <br /> ASSOCIATED BUILDING PERMIT#(if"applicable) <br /> MECHANICA1«PERMIT'APPLIOR I''I<ON PLUMBING:°PERMIT APPu ATI0N <br /> Type of Project: New Addn Alteration _Repair Type of Project: _New Addn !Alteration _Repair <br /> #of <br /> List of Fixtures #of #of <br /> Fixtures Fixtures List of Fixtures List of Fixtures List of Fixtures <br /> - . <br /> A/C-AiFixtures ' Fixtures r Handling Units Heat Pump 1. Toilet Backflow Preventer(Inside Btdg <br /> Forced Air Systems Unit Heater Bathtub Urinal <br /> Gas Piping 3n <br /> rl. .,,, P � " 'i3oiler lavatory(Wash Basin) Drinking Fountain <br /> Water Heater T^ <br /> Refrigeration Shower Floor Drain <br /> I Gas Fireplace Wood Stove Kitchen Sink&Disposal Grease"Trap <br /> Gas Ran Ducting Dishwasher Roof Drains <br /> Clothes Dryer Hookups Other Clothes-Washer-.e <br /> � e ;; asher — 4. Medical Gas <br /> Range Hood <br /> g Water Heater Other <br /> Exhaust Fan <br /> Sink(Service/t3ar7Moptetc) Other: <br /> SPRtNKL«ER.`=I suppilessioit <br /> BYSil t" <br /> Chemical or Water No.of Heads <br /> ACKNOWLEDGEMENT:I have reviewed this application and confirm the information contained herein is true end correct.Worts-done pursuant to this permit must comply with <br /> CiOranl fatlertl1,State:twit!local law The Wanting of a,oeneir dniytauthorizes approved work and no deviations therefrom.Deviations must first be authorized in writing from the <br /> gullo'Tn Official befor a nem,al ihor/jed,tinder any circumstance.':I am the owner,or f am authorized by the owner of this properly lo perform the work for which application is made, <br /> and i comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> 113wrie Authorized/igen ignature Date ' tel V 1 <br />