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PERMIT APPLICATION <br /> BUILDING/ MECHANICAL/PLUMBING /SIGN /SPRINKLER/DEMOLITION <br /> CITY OF EVERETT PERMIT SERVICES <br /> ' ' J 3200 CEDAR STREET,EVERETT,WA 98201 <br /> (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps©everettwa.gov I www.everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: 75;,P.a- 40'74-0 <br /> PROPERTY TAX#: <br /> LEGAL for new construction: Short Plat/subdivision 29/R�fLot No4'3 (attach copy of long legal description) <br /> Qi CONTACT INFORMATION <br /> OWNER NAME: �Q,e___J TENANT NAME(If Commercial):/)//0/96/4/14&' Agi/, zze. <br /> OWNER MAILING ADDRESS: STREET 1.,7Q , Y2a t j4L) <br /> CITY 6✓Vgce STATE/4,41 ZIP 9,,v_.0 L/ <br /> OWNER PHONE: .1,4,2.S' 9.5.?a't c OWNER EMAIL: <br /> CONTRACTOR NAME: 4,0t )40',. /e.a!) <br /> CONTRACTOR ADDRESS: STREET �� 3 � <br /> CITY/-(d}*--, S � STATE � ZIP 9�C� <br /> CONTRACTOR PHONE: /,2,5"--5,34 //// CONTRACTOR EMAIL: /ip6S t2 I)7 aih,471- At <br /> CONTRACTOR LICENSE#(REQUIRED): IPII 77/ a(pV'2 CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): hnol bO <br /> PRIMARY CONTACT: 0 OWNER )CONTRACTOR 0 OTHER(Please Specify) <br /> CONTACT NAM CONTACT PHONE: 440 �� ST(3 • <br /> Darnel �� CONTACT EMAIL: iOQkb14P/1 Y1 1/0-iW?Q1I• CDn't <br /> BUILDING PERMIT APPLICATION <br /> Existing Use of Building: Contract Price of Work:$A-9.00 <br /> Proposed Use of Building: `Heat Source: OGas ,'Electric ❑Other <br /> Building Type: ❑SFR-Detached OSFR-Attached 0 Duplex , Multi-Family-#of Units: ❑Commercial El Industrial <br /> Type of Project: New ❑Addition El Remodel ❑Repair DT.I. °Sign OSprinkler ❑Demolition ❑Change of Use <br /> DESCRIPTION OF WORK: <br /> / c -m ,sthsAi <br /> ASSOCIATED BUILDING PERMIT#(if applicable): <br /> MECHANICAL PERMIT APPLICATION PLUMBING PERMIT APPLICATION <br /> Type of Project: JNew _ Addn Alteration _Repair Type of Project: New _Adds 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 /> SI dt4?:16-11- � iPE �O3 -C� <br /> •wn: Authorized Agent Signature Date (Revised 9/23/2016) <br />