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PERMIT APPLICATION
<br /> '1141 —":"41BUILDING)mmCHANICAL/ PLUMBING /SIGN / INKLER/ DEMOLITION
<br /> : CITY OF EVERETT PERMIT SERVICES
<br /> ,4144" 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
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<br /> PROJECT SITE ADDRESS: --it )b VV 't kr', e_ PROPERTY TAX#:
<br /> LEGAL for new construction: Short Plat/subdivision Lot No. (attach copy of long legal description)
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<br /> OWNER NAME: 44e-r►Cilac v TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDR S: STREET
<br /> CIN !��!QAA STATE a ZIP l 0 O
<br /> OWNER PHONE: `+2s • 32b• (2(a 0 OWNER EMAIL:
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<br /> CONTRACTOR NAME: fO..�A-%DY1 1 6 A. �
<br /> I tsU l�prCl 0(11,1 Or)S
<br /> CONTRACTOR ADDRESS: STREET eo EJ 6,6 lei Q
<br /> CITY 1 - l r�K(rt Le STATE •NA-, ZIP ct$2 -0
<br /> CONTRACTOR PHONE: &Op •1.49Q-S. - G CONTRACTOR EMAIL: 1y-) l 1Klt.4> , acw)
<br /> CONTRACTOR LICENSE#(REQUIRED): �Tc F-P 6'1-4 C Ece 32 �1 CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): b 6g
<br /> PRIMARY CONTACT: ❑OWNER CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: - CONTACT PHONE: 3t0Q •.COS13 , CIQD0
<br /> dt.A.-1-‘49.. (ae.e.r,1,\A__r\ CONTACT EMAIL: (ify6) Zip kaa.—+)
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<br /> Existing Use of Building: Contract Price of Work:$ 2.. e)O
<br /> Proposed Use of Building: Heat Source: ❑Gas SElectric ❑Other
<br /> Building Type: AgFR-Detached ❑SFR-Attached ❑Duplex ❑Multi-Family-#of Units: ❑Commercial ❑Industrial
<br /> Type of Project: ONew ❑Addition ❑Remodel `Repair ❑T.I. ❑Sign ❑Sprinkler ❑Demolition ❑Change of Use
<br /> DESCRIPTION OF WORK:
<br /> R-L L ,ems I,Ake__ ek-r.ol k f
<br /> ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> .. 14� ANICAL�,I l '� 'rk10-77114 ,' I a, I.r !: MB.ING'.PERF RM.IC� -11W 4
<br /> 3 x. r r .� _ ����I,' ��.��
<br /> Type of Project: New _ Addn _Alteration _Repair Type of Project: _New _Addn _Alteration _Repair
<br /> #ofList of Fixtures #of List of Fixtures #of List of Fixtures #°f List of Fixtures
<br /> Fi urs
<br /> XFixtures 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 /> 4'i71 ” rERIrSUPPRESSIONiSY IIf,
<br /> Chemical or Water r 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 /> Alia/n ' City of Everett Official Use Only
<br /> 1 2ip [ 1(
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<br /> Owner/Au'I orized Agent Signature Date (Revised 9/23/2016)
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