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'IPPERMIT APPLICATION <br /> BUILDING/MECHANICAL/PLUMBING/SIGN/SPRINKLER/DEMOLITION <br /> 144g1 CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET,EVERETT,WA 98201 <br /> (P)425-257-8810 I FAX 425-257-8857 j(E)everetteps@everettwa.gov I www.everettwa.govlpermits <br /> .itiOagitaZtaltNA2C-WiNiM::i:IMSANWORCIAiget rSITE lftoitMAtieifiggtta:agMRPSggngNBPttMISVOV <br /> PRalintji SITKgRESS:A;e PROPERTY TAX#: <br /> LEGAL for new construction: Short Plat/subdivision Lot No. (attach copy of long legal description) <br /> taNittMatipiEMORMKROMINNO*1011SiTACTINIO.OAMACtiONM*Wfg:00:ROMMIPRNEgi:::g:WW,MOIAPPM <br /> OWNER NAME: Da.ta 5,q-A TENANT NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET 9//q O0.141 Av e <br /> crrY Ev elyei STATE WA zip 96 201 <br /> OWNER PHONE: (05) 271 -^ Lig 3 OWNER EMAIL: _915m.zoi 3519 gC011(4,.1.7.rdkir7" <br /> CONTRACTOR NAME: R 56 kdial Rol 6 611 <br /> CONTRACTOR ADDRESS: STREET 67 oil q944 PL. N1 ' <br /> CraY flig Ai 5k/ g STATE <br /> NJ ZIP <br /> CONTRACTOR PHONE:025j 320 6775 CONTRACTOR EMAIL: 5i2&i 5C./it ON1 g,;MO,U I, <br /> CONTRACTOR LICENSE#(REQuIRED): RF 01.P AP31441 N p CITY OF EVERETT BUSINESS/UcENS #(REQUIRED):57410// <br /> PRIMARY CONTACT: VIOWNER 0 CONTRACTOR D OTHER(Please Specify) I <br /> 1 4.1. <br /> CONTACT NAIVE: David, Ain 11 CONTACT PHONE:6Z) <br /> CONTACT EMAIL:d5 sr)p/./.4 piretcry, ,4 el <br /> kwstagtmaa-msioaonogsgosmattmo:AN:ogPottvtctiAro-aoxtrotarmomsmmtmyatoansm <br /> Existing Use of Building: R 0 den f,f Contract Price of Work:$ <br /> Proposed Use of Building: ge4dar K.q. Heat Source: ElGas OElectric ElOther <br /> Building Type: OSFR-DetachedMCSFR-Attached ODuplex 0Multi-Family-#of Units: OCommercial Ellndustrial 1 <br /> Type of Project: ONew I:Addition E1Remodel EIRepair 01.1. 0Sign EISprinkler ODemolition OChange of Use <br /> DESCRIPTION OF WORK: go 4 i /27,4 g t3et,f4 up5/64,/5 1 <br /> 1 'r <br /> ASSOCIATED BUILDING PERMIT#(if applicable): <br /> attit#0004:4104t#0000.000tONNOM ,,tagegattagMAVPIPINIOtggipt APPLICATION <br /> Type of Project: New Addn Alteration Repair Type of Project: _New ufAddn Alteration Repair <br /> #0! #of #of . #of <br /> Fixtures List of Fixtures List' of Fixtures List of Fixtures List of Fixtures <br /> Fixtures Fixtures Fixtures 1 <br /> A/C—Air Handling Units Heat Pump i Toilet 0/71./Pacicnbw Preventer(Inside Bldg) <br /> IForced Air Systems Unit Heater Bathtub Urinal <br /> Gas Piping Boiler ' / Lavatory(Wash Basin) Fountain <br /> king 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: il <br /> Exhaust Fan Sink(Service/Bar/Mop/etc.) Other: <br /> i <br /> K2ANS#11INktiEjOVSUPiRt.-&4:110,14 fiSYStea0i:iiil 1 <br /> Number of Heads <br /> r 1 <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 aw 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only 4 <br /> Owner/ /Au horized A igniitfure Da21/10 PERVII 627c1 1 <br /> (Revised 10/12/2015) <br /> 1 <br /> i <br />