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PERMIT APPLICATION
<br /> BUILDING/MECHANICAL/PLUMBING I SIGN/SPRINKLER/DEMOLITION
<br /> l��eliP,,,,s�/�'��_ CITY OF EVERETT PERMIT SERVICES
<br /> ' 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 /> (Blue or.Black Ink Only;Please)
<br /> PROJECT SITE INFORMATION ,,, -
<br /> PROJECT SITE ADDRESS: q 0 q P•I y,,e 54-. ve.0 41--i. to 4 qi a 1 PROPERTY TAX#: 00L43 T719 60070t)
<br /> LEGAL for new construction: Short Plat/subdivision Lot No. (attach copy of long legal description)
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<br /> 1 ONTACT INFORMATION ..
<br /> OWNER NAME: b.vei^r). Do rt 61,41, TENANT NAME(If Commercial): _
<br /> OWNER MAILING ADDRESS: STREET q©q 2,,kr, 54-
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<br /> air t kkgre`+-.}-1 - - STATE VV ` 4I ZIP t(U -t. .
<br /> OWNER PHONE: )..cj3j— 1OL — /SO q . OWNER EMAIL: 6j 42r3^ bos ,��cHar� /1!)�ai-r►t , .cut,
<br /> CONTRACTOR NAME: 17`e INS S t A.e t:111.11!0.,5
<br /> • CONTRACTOR ADDRESS: STREET
<br /> �/y1 O7.3; 41 pI U/
<br /> CITY Pel I U/CZ libSTATE ZIP t 'gaf-1S—
<br /> CONTRACTOR PHONE: it t — ql g3....fj 3j 3 CONTRACTOR EMAIL: -1.:,,,N,gp 13e4-ei ico-v&-
<br /> CONTRACTOR LICENSE#(REQUIRED): c L R E.G561ZWE CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): egt 0
<br /> PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR 0 OTHER(Please Specify)
<br /> • CONTACT NAME: CONTACT PHONE: eft/3..-53 53
<br /> Y" l,,t 5 4t6Ir< CONTACT EMAIL t"`,1 pit S® get rie .c ow.
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<br /> BUII.LDiNGPERMIT APPLICATION s,; ,x,, ,> n.,'
<br /> Existing Use of Building: Ci j,,it row,-( fa,ps,Ar,,,.,e Contract Price of Work:$ I/O1400
<br /> Proposed Use of Building: Heat Source: ❑Gas CElectric ❑Other
<br /> Building Type: PLSFR-Detached ❑SFR-Attached ❑Duplex ❑Multi-Family-#of Units: ❑Commercial ❑Industrial
<br /> Type of Project: ❑New ISAddition ❑Remodel El Repair OT.I. OSign ❑Sprinkler ❑Demolition ❑Change of Use
<br /> DESCRIPTION OF WORK: 144 lfaJnl, OP. il/liytj sal J- jy$ jyt
<br /> ASSOCIATED BUILDING PERMIT#(if applicable):
<br /> v MECHANICAL PERMIT<APPLICATION ;PLUMBING';PERMIT APPLICATION
<br /> Type of Project: _New ,,lc:, 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 /> NC—Air Handling Units 'F. 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 /> Bl'IiINKLER 1 SUPPItESSIQN$XSTEM
<br /> 'Chemical or Water I 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.lam 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 /> w...... PERM! n
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<br /> ••'ner/•uthoriz;77-gent Signature Dat= (Revised 9/23/2016)
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