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grr 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 I FAX 425-257-8857 1(E)everetteps@everettwa.gov 1 www.everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: 54 I (' g Dac9 1-"LA, PROPERTY TAX#:0 t 012_0 50oo00O <br /> LEGAL for new construction: Short Plat/subdivision Lot No. (attach copy of long legal description) <br /> CONTACT INFORMATION <br /> OWNER NAME: 1ti) co� �`(iW� LL,(� TENANT NAME(If Commercial): -`*ci( <br /> OWNER MAILING ADDRESS: STREET gcto 1541-%AV e S U <br /> cnv j3.`II f f 1, e STATE �A.I A ZIP 'go 010 <br /> OWNER PHONE: 1 (� ` V v--- OWNER EMAIL: YYY <br /> CONTRACTOR NAME: Kelt( i L"tr t LoryV `� <br /> CONTRACTOR ADDRESS: _ ` STREET > (> t- AJ �C( S <br /> CITY RDart Vec �,C\ STATE W Pc. ZIP 9,&113 <br /> CONTRACTOR PHONE: ;j6,0-1-1'P4 --1 ,5)- CONTRACTOR EMAIL:S t t4r e 6:4 al eps i G)yt. ( j'v•- <br /> CONTRACTOR LICENSE#(REQUIRED):M Ey�2.,S(,s3— g CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): <br /> PRIMARY CONTACT: 0 OWNER MrCONTRACTOR 0 OTHER(Please Specify) <br /> CONTACT NAME: p� ,� CONTACT PHONE: )6)0 -1-12)-1— i=11' t� <br /> tan,It IA' gvt,tt- CONTACT EMAIL: 5tc.(11nl eet, (.1.�)t,'rS IC�{7- /.�'✓v` <br /> BUILDING PERMIT APPLICATION rix) <br /> t <br /> Existing Use of Building: Contract Price of Work:$ (�L�v C) <br /> Proposed Use of Building: Heat Source: ❑Gas ❑Electric ❑Other <br /> Building Type: ❑SFR-Detached ❑SFR-Attached ❑Duplex ❑Multi-Family-#of Units: ❑Commercial ❑Industrial <br /> Type of Project: ❑New ❑Addition ❑Remodel ❑Repair ❑T.I. sign ❑Sprinkler El Demolition ❑Change of Use <br /> DESCRIPTION OF WORK: 12'/tyn,l Al will L S i/Av 1 rot, 6:‘,.,..1 C la <br /> (ASSOCIATED BUILDING PERMIT#(if applicable): <br /> MECHANICAL PERMIT APPLICATION PLUMBING PERMIT APPLICATION <br /> Type of Project: _New _ Addn _Alteration _Repair Type of Project: New _Addn _Alteration _Repair <br /> #of List of Fixtures #of List of Fixtures #of List of Fixtures #of List of Fixtures <br /> Fixtures Fixtures Fixtures 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 I 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 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.I am the owner,or I am authorized by the owner of this property to 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 /> r • / PERMIT# <br /> y1)01I OLA- ()0 <br /> Owner/Authorized Agent Signat e D to (Revised 9/23/2016) <br /> tz <br />