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PERMIT APPLICATION
<br /> -' BUILDING/MECHANICAL/PLUMBING/SIGN/SPRINKLER I DEMOLITION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET,EVERETT,WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857 i(E)everettepag/everetbm.gov I www.everettwa.gov/pertnits
<br /> govlpermits
<br /> Black Onhir lr - ,-. EiN 14A 1O ;. . . d .
<br /> PROJECT SITE ADDRESS;toTte ,.f ap, ,(^ 1/4„t, ;,,, A PROPERTY TAX#:
<br /> LEGAL for new construction: Short Plat/subdivision Lot No. (attach copy of long legal description)'
<br /> OWNER NAME: C yZ ( x c&,.\C; TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET &a""1 '` i)e'rl`t \ex el e....
<br /> Cm, r.(342.4 tk1 ) STATE 11..�4H ZIP q a()3
<br /> OWNER PHONE:Lk as - `.a lock 1-1 OWNER EMAIL. aeu r r ` ler eda
<br /> CONTRACTOR NAME: ` n,f ,C- -t yY \,et 4 i:YNFs, C.44.....04..ek C t
<br /> CONTRACTOR ADDRESS: STREET sq o g ``vrt s , E, ,
<br /> CITY M Y , s ip STATE A:. ZIP S FS
<br /> CONTRACTOR PHONE:LL `}. -j'1- j -1t3,4 CONTRACTOR EMAiL:i 1�.to(Co (1l,J-A,, fy k. h- t A&4"Mt
<br /> CONTRACTOR LICENSE#(REQUIRED) CO t i..a,)U) CITY OF EVERETT BUSINESS LICENSE#(REQUIRED)
<br /> PRIMARY CONTACT: ❑OWNER ONTRACTOR E7 OTHER(Please Specify)
<br /> CO TACT NAME:E CONTACT PHONE: I . `. ..�?,, . L),
<br /> OW`,(‘‘k l \t°1c _
<br /> CONTACTEMAIL: {
<br /> 0, ,* ,
<br /> O _R
<br /> Existing Use of Building: Contract Price of Work;$, t: .i-i
<br /> Proposed UseBuilding: Heat Source: ❑Gas DElectric DOther
<br /> Building Type: SFR-Detached I FRAched ❑Duplex DMulti-Family-#of Units:_______ ❑Commercial ©Industrial.
<br /> Type of Project: New ❑Addition ❑Remodel lRepair OT.I. °Sign °Sprinkler °Demolition ❑Change of Use
<br /> DESCRIPTION OF WORK: ,
<br /> • 41—'‘ -C. t IN ,‘ 6L- 4t-k ri.0*-414...... . :kt-c en e 44.4
<br /> ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> 14 rSr, ° * �4 : ..:... ., a .. •„., h -•a f.:**1 001#01,— �C a1:::.,s c.,T "G
<br /> Type of project: _New Addn t Alteration _Repair Type of Project: New _Addn _,Alteration _Repair
<br /> #of List of Fixtures #of List of Fixtures #of List Fixtures #'elf List of Fixtures
<br /> Fixtures Fi duras Fixtures Paltti'es
<br /> A/C—Air Handling Units Heat Pump Toilet Backflow Preventer(Inside Bldg)
<br /> 1 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/Mopletc.) Other:
<br /> 0. M 1�.
<br /> Chemical or Water t_ No.of Heads
<br /> ACKNOWLEDGEMENT:l 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 Jaw.The granting of a permit only authorizes approved work and no deviations therefrom.Deviations.must first be authorized in writing from the,
<br /> Building Offiial before being authorized under any circumstance,lam'the owner,ori am authorized. , :.owner cif this property to perform the work for which application is made,
<br /> and I comply with the State Contractors Law 18.27 RCW end 2915,200A WAC.
<br /> i ', , /O4ç,, ] City of Everett OfficialUe Only
<br /> , PERMIT#
<br /> OwneriAu horized Agent Signature Date (Revised 9123/2016)
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