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PERMIT APPLICATION
<br /> /0111P—
<br /> BUILDING/M�ANICAL/PLUMBING/SIGN /SPRING/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
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<br /> I A: �dn: , .�. �.�7 .:,. y � . a ..,,,,,:,., � ..ya ,.s _„ f 7. K.. ,iiw .-, :_
<br /> PROJECT SITE ADDRESS: Z'7( `fit J�4-L1/�� Da.I PROPERTY TAX#:Lf 7L(--ocY> Ocn'-4=z93
<br /> LEGAL for new construction: Short Plat/subdivision Lot No. (attach copy of long legal description)
<br /> _- ...,ilv,L, �!��� 41 NX****ff' - d„ Wim.»,+i
<br /> OWNER NAME: s_11 e.e(f TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET 2'"71 -.7ALQ/ i2- c_. g/�
<br /> e�. CITY (4- STATE f G as ZIP
<br /> °OWNER PHONE: 206 I{/O- )00® OWNER EMAIL: rcksS(p_.....SSS Gpi C4laryY`.
<br /> CONTRACTOR NAME: To L V „Jai t ty /0110 re.ctQ-i,.( e„--4. 0 -
<br /> CONTRACTOR ADDRESS: STREET ��3(p i (p CC”( // 1,41„,„:_--ft g
<br /> CITY (i-✓e i'eft---- STATE -`-' A ZIP e:19 41411
<br /> CONTRACTOR PHONE: (2., 7 O C,5 ie./ CONTRACTOR/ EMAIL: 0-i Alf CO td>=:n t E'+ 6L,as CG S t• S
<br /> CONTRACTOR LICENSEE#(REQUIRED): (DO Z- Z C2 i 6'5 CITY OF EVERETT BUSINESS LICENSE#(REQUIRE0:3(512, ),,�
<br /> #
<br /> PRIMARY CONTACT: DOWNER 0 CONTRACTOR 0 OTHER(Please Specify)
<br /> C CT NAME: CONTACT PHONE: 0406_9v4)„J
<br /> ?�$ til 12-tAi 12-icg2 CONTACT EMAIL: rasS' iv}, •.v, 40, C,1w- -
<br /> Existing Use of Building: S ihi k_ ,,-IL1Lil )' Contract Price of Work: v
<br /> Proposed Use of Building: 6JJJ1 Heat Source: ❑Gas ❑Electric ❑Other -
<br /> Building Type: ❑SFR-Detac.hed © R-Attached ❑Duplex ❑Multi-Family-#of Units: uC o nt -rcial ❑Industrial
<br /> Type of Project: ONew L7Addition ❑Remodel ❑Repair ❑T.I. ❑Sign ❑Sprinkler ❑Demolition ❑Change of Use
<br /> DESCRIPTION OF WORK: A-19 0
<br /> 190 - EX 1 -.1./1
<br /> ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> 11112222 ft - a e ,,.<. _ 111 ZIONVICIZZEL 02:1"771"13211 :;,.,b 4'e
<br /> `Type of Project: _New_ Addn _Alteration _Repair
<br /> #of List of Fixtures #of = #of List of Fixtures #of
<br /> Fixtures Fixtures Fixtures Fixtures
<br /> A/C-Air Handlin. Units -Er'mp -Toilet -[ '-o""P -'- t- (I .- BI..B
<br /> Forced Air Systems MINCEZZEIMI _Bathtub -d rinal
<br /> AWE Gas Piping -1d Boiler -Lavato (Wash Basin -_Drinking Fountain
<br /> Water Heater /ARefrieeration -Shower ,-Floor Drain
<br /> Gas Fireplace A.
<br /> Wood Stove -Kitchen Sink&Dispos.,A-Grease Trap
<br /> Gas Range _-Ducting -Dishwasher --Roof Drains
<br /> =Clothes Dryer H.. ups -Other: -Clothes Washe--Medical Gas
<br /> Rene HoodAl IZEIM37. 11-Other:
<br /> = �r M e/Bar/Mop/etc.) Other:=
<br /> MINEME
<br /> Chemical or Water -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.l 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 /> City of Everett Official Use Only
<br /> 14----
<br /> A (.4
<br /> Owne/Authorized Agent Signature Dat (Revised 9/23/2016)
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