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PERMIT APPLICATION <br /> BUILDING/MECHANICAL/PLUMBING/SIGN/SPRINKLER/DEMOLITION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET,EVERETT,WA 98201 <br /> 'Al1444iW4 <br /> (P)425-257-8810 ( FAX 425-257-8857 1(E)everetteps©everettwa.gov I www.everetfwa.gov/permits <br /> {4* �Ir BIaI k Ilnttc D a e) 'PR�.p} iITE IN-I't Rtlfilll" ION <br /> PROJECT SITE ADDRESS:Leta) V I L {.C,fi; tt=' 1' PROPERTY TAX#: <br /> LEGAL for new construction: Short Plat/subdivision Lot No. (attach copy of long legal description) <br /> 0O A 010 <br /> OWNER NAME: r C)el ci {'"tcl TENANT NAME(If Commercial): <br /> OWNER MAILING ADDRESS: sTREEr 1,0 4 �r} V C-1,0 %GI <br /> CITY -e STATE (IDOL ZIP (4 („9-61 <br /> OWNER PHONE: OWNER EMAIL: <br /> ,,.t_ am} ,� } <br /> CONTRACTOR NAME: !y [(( s j'�''ti 1` 0+-1 Y1 `- R 1 v� <br /> CONTRACTOR ADDRESS: STREET;yF 'T J% !/1 ] f /Y� f <br /> CITY + y�`rC...t p� V STATE 14304,-- ZIP i,,,,- q 1,.�O�j <br /> CONTRACTOR PHONE:L.4- S 3a � 404)-("'�1 CONTRACTOR EMAIL: jV } 66-- ✓LvvtA hot Cc c4, <br /> CONTRACTOR LICENSE#(REQUIRED): l/"\(,�F {,,t,4s' hot. b s Li`stn) CITY OF EVERETT BUSINESS:LICENSE#(REQUIRED.): :b grk-4 I <br /> PRIMARY CONTACT: D OWNER S; ONTRACTOR 0 OTHER(Please Specify) <br /> CONTACT NAME: ( CONTACT PHONE: L 3 -`t-{� -,`",,� <br /> CONTACT EMAIL.""} )r a t.-jU`Y>t./ <br /> .!' y')- -_I <br /> Existing Use of Building: Contract Price of Work: <br /> Proposed Use of Building: Heat Source: rliogas DElectric °Other <br /> Building Type: °SFR-DetachedFR-Attached °Duplex °Multi-Family #of Units: °Commercial °Industrial <br /> Type of Project: ew °Addition DRemodei tepair DT.I. ['Sign °Sprinkler °Demolition °Change of Use <br /> DESCRIPTION F WORK:. t l K o 1� i, t 4: _ ,_inc v...e to let <br /> C- -;- -- <br /> t� ex a, d kiGt 1 t p <br /> ASSOCIATED BUILDING PERMIT#(if applicable): <br /> iV it }C PERPA1T APPLICA0:04; PL BI ►P I' '1.IC'AEtON .. <br /> Type of Project: _New Addn Alteration Repair Type of Project: _New Addis Alteration Repair <br /> #of List of Fixtures #of List of Fixtures #of Llst of Fixtures #°f List of Fixtures <br /> Ffxtures Fixtures Fixtures Fixtures <br /> A/C—Air Handling Units j 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/BarlMopfetc.) Other: <br /> Chemical or Water 1 No.of Heads <br /> ACKNOWLEDGEMENT:I have reviewed this application and confirm the infoimatian contained herein is true and correct.Work done pursuant to this permit mustcomply 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.tam the owner,ort am authorized by the owner of this property to perform the work for which application is made, <br /> and l comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> eCity of Everett Official Use Only <br /> \ I PE711 <br /> cgo � — o2�- <br /> Owner/Authorized Agent Signature Date (Revised 9/23/2016) <br />