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PERMIT APPLICATION
<br /> ASIP/At*/—A,, BUILDING/ MECHANICAL/PLUMBING/SIGN /SPRINKLER/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
<br /> 48141411kk� reMiR *4' '„0 N0,0 #9:0 " ',,I4''-72;i:- a.
<br /> PROJECT SITE ADDRESS: Sot)d it c, Ah e //e-r- eve PROPERTY TAX#: a14 C� 7 35-3
<br /> LEGAL for new construction: Short Plat/subdivision Lot
<br /> y .�,` JNo. (attach copy of long legal description)
<br /> ", rad- __.� rr' "-.�-.-' a'y"> 'a r;. M �
<br /> :'ll Alr , /,,til$00l�f�: 4.itc. :t rte; ��`..>„ .. A 011
<br /> OWNER NAME: 46t�C,p T p/ Se,vr e,$ Lc `, e %4C TENANT NAME(If Commercial): 4+64/ fik e.4 /Lf'e/1
<br /> OWNER MAILING ADDRESS: STREET P.0 fpm/ c,// 933 '
<br /> CITY VL /k.,/,oi, STATE 4/}4 ZIP q 85W-(j933
<br /> OWNER PHONE: 360 g 7 0 t13S OWNER EMAIL:
<br /> CONTRACTOR NAME: 44//`"e p li/th£Y1G7/)')r t /�y Atli/42m 4
<br /> CONTRACTOR ADDRESS: STREET /711 J%�E' ,57 5-6" 'tIY
<br /> CITY /y1 c',, Ire)r= STATE 41,0o z P y g.-77.2
<br /> CONTRACTOR PHONE: 1.1,":-3$7.7--2 „;22 CONTRACTOR EMAIL: Al 11c /4A-44 fI Cost
<br /> CONTRACTOR LICENSE#(REQUIRED):
<br /> .jp 3 3-.:-C J CITY O^-F EVERETT
<br /> VERETT BUSINESS LICENSE#(R.EQUIRs..:ESD_)-..:3<. , D
<br /> PRIMARY CONTACT: 0 OWNER I'ONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: C/
<br /> CONTACT PHONE: ,7$. 3/� 9� 7 ' 2
<br /> ill f1'e /440 u/7 Z r)17J 4 CONTACT EMAIL: ley,/, /� J (,/r�/,4 ; . or✓i I
<br /> " ,,m r._..,,..., �..�_> t...0 T ..5 -,x: 4 , '' Al a % _ ',",..,,7! ,:'-it
<br /> Existing Use of Building: Q C Contract Price of Work:$ 31 D GI, bD
<br /> Proposed Use of Building: Heat Source: ❑Gas 0 Electric ❑Other
<br /> Building Type: ❑SFR-Detached ❑SFR-Attached ❑Duplex ❑Multi-Family-#of Units: IaCommercial ❑Industrial
<br /> Type of Project: :New DAddition L 2emodel DRepair ❑T.I. ❑Sign ❑Sprinkler ❑Demolition ❑Change of Use
<br /> DESCRIPTION OF WORK::1-
<br /> 4 a 1 JAck,�
<br /> 0 lend sf�X ,,�e,,,,. ip-ec. .
<br /> ASSOCIATED BUILDING PERMIT#(if applicabj(`}'�,le): � ^j t
<br /> Lrfgrall
<br /> Type of Project: _New _ 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 /> A/C—Air Handlin• Units —Heat Pump —Toilet — :ac ow •reven er UMEMEMIN
<br /> Forced Air Systems —Unit Heater a 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 D er Hookups —Other: —Clothes Washer —Medical Gas
<br /> Range Hood —Water Heater —Other:
<br /> Exhaust Fan _Sink Service/Bar/Mop/etc. WAIN Other:
<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.lam the owner,or lam 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 /> �/J City of Everett Official Use Only
<br /> �"/�C / cage, 3 o7 .? V' PERMIT#,, V„, ,,,
<br /> Owner/Authorized Agent Signature ate (Revised 9/23/2016)
<br />
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