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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 I www.everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: 15 SW Everett Mall Way -A PROPERTY TAX#: 2832416 <br /> LEGAL for new construction: Short Plat/subdivision Lot No. (attach copy of long legal description) <br /> CONTACT INFORMATION <br /> OWNER NAME: Molina Medical Management, Inc. TENANT NAME(If Commercial): Molina Health Care <br /> OWNER MAILING ADDRESS: STREET PO Box 22819 <br /> CITY Long Beach STATE CA z,P 90801 <br /> OWNER PHONE: 562-435-3666 OWNER EMAIL: <br /> CONTRACTOR NAME: Northwest Sign & Design AI 1,0 Sr i 3 <br /> CONTRACTOR ADDRESS: STREET 17201 Beaton Rd. SE J <br /> CITY Monroe STATE WA ZIP 98272 <br /> CONTRACTOR PHONE: 425-844-6415 CONTRACTOR EMAIL: jeff@nwsigns.com <br /> CONTRACTOR LICENSE#(REQUIRED): NWSIGS*84201 CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): 053987 <br /> PRIMARY CONTACT: 0 OWNER 'CONTRACTOR 0 OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE:4255-844-6415 <br /> Jeff Carl CONTACT EMAIL: jeff(C�nWSIgnS.com <br /> BUILDING'PERMIT APPLICATION <br /> Existing Use of Building:Medical Contract Price of Work:$8,000 <br /> Proposed Use of Building: Medical Heat Source: El Gas ❑Electric ❑Other <br /> Building Type: ❑SFR-Detached ❑SFR-Attached ❑Duplex ❑Multi-Family-#of Units: IRCommercial El Industrial <br /> Type of Project: ❑New ❑Addition ❑Remodel ❑Repair ❑T.I. IRSign ❑Sprinkler ❑Demolition ❑Change of Use <br /> DESCRIPTION OF WORK: <br /> Installation of (2) illuminated wall signs <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:1 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 c mply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> PERMIT# <br /> 1 ) Gf>' t S. C-1 g°7 IOCI(oa <br /> Owne t .G 'r A.-• Signature Date (Revised 9/23/2016) <br /> q:.) <br />