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PERMIT APPLICATION
<br /> BUILDING I MECHANICAL/PLUMBING /SIGN I SPRINKLER/DEMOLITION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> ' 3200 CEDAR STREET,EVERETT,WA 98201
<br /> (P)425-257-8810 1 FAX 425-257-8857 1(E)everetteps@everettwa.gov I www.everettwa.gov/permits
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<br /> PROJECT SITE ADDRESS: ICI 7O vU' •'tGIM w 041 , 'b PROPERTY TAX#: et t 3O U,;O(o G'O D
<br /> LEGAL for new construction: Short Plat/subdivision i t:Y'l i... $No. 3 (attach copy of long legal description) 56t T 11 0
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<br /> OWNER NAME: t J4 , dw kpytm:54 CO ( TENANT NAME(If Commercial): 5A'itg- 45 /3W,�ek
<br /> OWNER MAILING ADDRESS: STREET t I n o 5(,t ytAl'VI,L-U�t A -t!
<br /> CITY 5CGt.4f(, STATE U) ZIP of 5 0
<br /> OWNER PHONE: OWNER EMAIL: 1,-(.4,,kcCOt t conk
<br /> CONTRACTOR NAME: IV1 e*y)) 124.41 C(97A.rJMitzkftti,t 41110
<br /> CONTRACTOR ADDRESS: STREET 11(45 I -Ul0 ll��� r te. �j G A / }�
<br /> CITY g(%tO ItW A4kS�jt STATE A ZIP 7 g2-11
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<br /> CONTRACTOR PHONE: ID& °V I X2.1% CONTRACTOR EMAIL: Da,Vt,. yko'yr$ZF , L+tI' Ci Wk.
<br /> CONTRACTOR LICENSE#(REQUIRED): M.Ei ra-cce- q Soto CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): 53'05 3
<br /> PRIMARY CONTACT: 0 OWNER CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: Wtht Wm.." CONTACT PHONE: jp(p 4011 ' LZ�g
<br /> CONTACT EMAIL: g'QAA cd uthyp)2,6$elf-G[c .cowl,
<br /> Existing Use of Building: O Contract Price of Work:$ tz1 et D
<br /> Proposed Use of Building: ( i Heat Source: ❑Gas Electric CI Other
<br /> Building Type: ❑SFR-Detached ❑SFR-Attached ❑Duplex ❑Multi-Family-it of Units: 76ommercial ❑Industrial
<br /> Type of Project: ❑New ❑Addition YRemodel ❑Repair ❑T.I. ❑Sign ❑Sprinkler ❑Demolition ❑Change of Use
<br /> DESCRIPTION OF WORK:
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<br /> D� of o -twr wt[ 4- � 'k a t rS92-12 $ Coytc,
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<br /> ASSOCIATED PERMIT#(if applicable): .1
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<br /> ;MECHANICAL PERMIT,APPLICATION: . ,. =? PLUMBING PERMIT,APPLICA'T�ON, ;
<br /> Type of Project: _New _ Addn _Alteration _Repair Type of Project: _New _Addn Alteration _Repair
<br /> #of #of List of Fixtures 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 /> 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.I 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.lam 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 /> 1� M 1 g 1367c1&02 -0 k
<br /> Owner/Authorized Agent Signet Date (Revised 9/23/2016)
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