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I I PERMIT APPLICATIO <br /> BUILDINI/ MECHANICAL/ PLUMBING/SIGN I S RINKLER/ DEMOLITION <br /> "IP.Imo' _ CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET,EVERETT,WA 98201 <br /> (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov www.everettwa.gov/permits <br /> �"B`�'{�`=r ."� -^-e/{�`_ ]I'I!;/. ��, .�qty w���s aRt �Jyas eRM � .1''. '�,a. _- � s_�-c -��, :.. <br /> 1131 .` ._. ..''S v�_..'St`ti irWif t 4.. ,`�. ��.A., m)= ra'N�.�,rA 'a . e�:.ZC ..._:2. .�` f1,1 . S,xr... 4. ZAt <br /> PROJECT SITE ADDRESS: f 0okey f/ C a,y,��w (.A.) R c r,1. `/-y2Oy PROPERTY TAX#: <br /> LEGAL for new construction: Short Plat/subdivision " Lot No. (attach copy of long legal description) <br /> W Z V:'.a'e. TM, M 140 *V "10;':k.:-.V:;.! moi` ,',t!41.1*?, <br /> !4111 r`x"AMISS <br /> OWNER NAME: (A.) S 0 0 TENANT NAME(If Commercial): <br /> cT <br /> OWNER MAILING ADDRESS: STREET / 0 2 7 LC q j i Loa,/ <br /> p /� <br /> CITY 8 Ute.!'2. t STATE Gull .. ZIP CIrY.10 <br /> OWNER PHONE 20 /O.S /O. -' 6 3 S c OWNER EMAIL: (,JCS I I S / (,,.,S D Of- (41 w <br /> CONTRACTOR NAME: c')(J (/11/4_ -. w a5 4 40, 5.1-u1'' pr PS. © F Tr(414%5 puv'i- - IuA <br /> CONTRACTOR ADDRESS: STREET <br /> CITY STATE ZIP <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> CONTRACTOR LICENSE#(REQUIRED): CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): <br /> PRIMARY CONTACT: WNER 0 CONTRACTOR 0 OTHER(Please Specify) .. <br /> CONTACT NAME: CONTACT PHONE: C - 7/0 - 6 3 .�"? <br /> G� \." s (,0 c.& S CONTACT EMAIL: Gorr)1 7 w -- - o") <br /> rte O.' U r 4 . h . , gg R <br /> Existing Use of Building: Contract Price of 'ork:$ <br /> Proposed Use of Building: Heat Source: 0 . ■ - =: er <br /> Building Type: ❑SFR-Detached ❑SFR-Attached ❑Duplex ❑Multi-Family-#of Units: ❑Commercial ❑Industrial <br /> Type of Project: ❑New ❑Addition ❑Remodel ❑Repair ❑T.l. ❑Sign ❑Sprinkler ❑Demolition ❑Change of Use <br /> DESCRIPTION OF WORK: <br /> ASSOCIATED BUILDING PERMIT#(if applicable): <br /> 0M °4'0 V111034'/ 0011 ,..`f litS CIMMI NIB"!KW ERVIMOttO *OWIESNE .. <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 /> NC—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 /> J 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 /> 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 /> caner/A hori ed Agent Signa Date (Revised 9/23/2016) <br />