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PERMIT APPLICATION
<br /> BUILDING/MECHANICAL/ PLUMBING/SIGN /SPRINKLER/DEMOLITION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> "11P441,447-/7-4illg-1.- - 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 /> (Bt0 Qr BI f� kin! ,610 474• .. : ;iO4,0 ITE IN0a100/10 ," ,!
<br /> PROJECT SITE ADDRESS: I-72`i 1,..), M qr Ile_ leo Ln 3 5 PROPERTY TAX#:
<br /> LEGAL for new construction: Short Plat/subdivision Lot No. (attach copy of long legal description)
<br /> F
<br /> :CONTACT INFGRMATION -4
<br /> OWNER NAME: (* �Ver-0-4-- TENANT NAME(If Commercial):eA�� ..I IUM (f UV V I
<br /> OWNER MAILING ADDRESS: STREET iI 20 S C c,, 4 reto,n v.➢5y at. 2ov
<br /> CITY pV elle\ 1 STATE w S ZIP 9 g 1
<br /> OWNER PHONE: 442-S-330- 753e OWNER EMAIL: Dq,k„ d f®r`k-e4exer�-'�FmCott'1
<br /> CONTRACTOR NAME: C)is EA Ial S b Con SW.)dr c 5
<br /> CONTRACTOR ADDRESS: STREET 34-1 Sb A;c'p i- At— 01)11 001 5 b2
<br /> CITYtics n.5\.,q,"\ STATE \,...)C. ZIP q 2;2_2„4p
<br /> CONTRACTOR PHONE: 3(Qp--73.4-. 3(„,,r, CONTRACTOR EMAIL: DI l r ( VAG,C $ -,a, Orly.tErel
<br /> CONTRACTOR LICENSE#(REQUIRED) D.T MQl�Co%f,k A CITY OF EVERETT BUSINESS LICENSE#(REQUIRED) M,l
<br /> a _ „..,,ri _ ,. �. ._. „�.�,.,.... oma„,..—,„ __—_..., ,.M,.,. _ .. .. ...,,.. ,.v,.«..,,...
<br /> PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR P2 OTHER(Please Specify)_Ac5i 5kgA--eXb ^ / jJMsno cije C”
<br /> CONTACT NAME: CONTACT PHONE: f Z53.30 'j 53€'
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<br /> CONTACT EMAIL: clrt GO fcckbee C.-#,Ct xn
<br /> a '`mow` €
<br /> Existing Use of Building: o `C etre, i Contract Price of Work:$ Zj,. /S'
<br /> Proposed Use of Building: 6 -4-Ce_ / re.A-0.; i Heat Source: ❑Gas ❑Electric El Other
<br /> Building Type: ❑SFR-Detached ❑SFR-Attached ❑Duplex ❑Multi-Family-#of Units: Commercial ❑Industrial
<br /> Type of Project: El New ❑Addition 'Remodel CI Repair ❑T.I. ❑Sign ❑Sprinkler ❑Demolition El Change of Use
<br /> DESCRIPTION OF WORK: nePlgce _ A'C3-)O eaS4- e^1 &oo 4oe e,,+p .)fQ 0(A-t -s..
<br /> ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> %-kMF,g031 I0 k ttMitlAPP ,IC 1C ' ` ,' IiwtoiNG,PE "hi?a i l'T1ON,w.
<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 Z 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 /> oma !' SPR1N ER'11$00PR STO,,,. 1 STEM R:
<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 comp! with the State Contractors Law 18.27 RCW and 296.200A WAC.
<br /> City of Everett Official Use Only
<br /> / �j /y°p J/©) PERM�yIIT�/#
<br /> er/Auth,rized .4ent Signature Da (Revised 9/23/2016)
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