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PERMIT APPLICATION <br /> #11/1 10,-4 <br /> 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 I(E)everetteps@everettwa.gov I www.everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS:916 Pacific Ave it PROPERTY TAX#:29053000200100 <br /> LEGAL for new construction: Short Plat/subdivision Lot No. (attach copy of long legal description) <br /> CONTACT INFORMATION <br /> OWNER NAME: Providence Health and Services-Washington TENANT BUSINESS NAME(Commercial): PRMCE Pacific Campus <br /> • <br /> OWNER MAILING ADDRESS: STREET 105 W.8th Ave.,Suite 7040 i'—'6•14.e <br /> Wort tr iri 0., ( C <br /> CITY Spokane STATE WA ZIP 99204 J <br /> OWNER PHONE: 425-218-0919 OWNER EMAIL:james.grafton@providence.org <br /> I <br /> CONTRACTOR NAME:Providence Facilities Department — 0 W (Ap_,r <br /> CONTRACTOR ADDRESS: STREET916 Pacific Ave <br /> CITY Everett STATE WA ZIP 98201 <br /> CONTRACTOR PHONE:425-258-7854 CONTRACTOR EMAIL:lloyd.christensen@providence.org <br /> CONTRACTOR LICENSE#(REQUIRED): CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): 47317 <br /> PRIMARY CONTACT: ID OWNER 0 CONTRACTOR 0 OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE:425-258-7854 <br /> Lloyd Christensen CONTACT EMAIL:Iloyd.christensen@providence.org <br /> BUILDING INFORMATION <br /> Existing Use of Building:hospital-licensed outpatient clinic Contract Price of Work: $11,972 <br /> Proposed Use of Building:hospital-licensed outpatient clinic Heat Source: OGas ❑Electric ❑Other <br /> BUILDING USE: ❑SFR ❑Townhouse ❑Duplex ❑ADU ❑Multi-Family-#Units: ❑✓Commercial ❑Accessory Structure <br /> Type of Project: ❑New Addition ❑✓Remodel Repair ❑T.I. Sign ❑Sprinkler ❑Demolition ❑Change of Use <br /> DESCRIPTION OF WORK: Minor remodel within an existing outpatient clinic. <br /> ASSOCIATED BUILDING PERMIT#(if applicable): 81710-042(previoius city permit-expired);60807059(Washington State DOH Construction Review) <br /> MECHANICAL PERMIT APPLICATION PLUMBING PERMIT APPLICATION <br /> Fixture Fixture Fixture Fixture <br /> Count List of Fixtures Count List of Fixtures Count List of Fixtures Count List of Fixtures <br /> NC-Air Handling Units Gas Piping Backflow Preventer(Inside Bldg) Shower,Tub,or Combo <br /> Boiler Gas Range Clothes Washer Sink-Commercial(3-comp,prep,floor) <br /> Clothes Dryer _Heat Pump&Ductless Dishwasher Sink-Residential(kitchen,bath,bar) <br /> Duct System(Remodel) Refrigeration Drinking Fountain Sink-Utility,laundry,mop <br /> Exhaust Fans(Residential) Commercial Ventilation Floor Drain Toilet <br /> Exhaust Hood(Type I) (Not Heat/AC system) Hose Bibb Urinal <br /> Exhaust Hood(Type II) Water Heater Interceptor-Grease Waste/Water Piping Repair <br /> Exhaust Hood(Residential) Wood Stove Interceptor-Sand/Oil Water Service(behind meter) <br /> Forced Air Systems Other: Medical Gas Water Valves or Fixtures <br /> Gas Fireplace/Insert/Log Roof Drains Water Heater <br /> SPRINKLER/SUPPRESSION SYSTEM Sewage Ejector or Sump Pump Other: <br /> Water Suppression System No.of Heads <br /> Chemical Suppression System 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 /> City of Everett Official Use Only <br /> PERMIT# (� q <br /> ���� /i �. .-Z5'7. _. ' / ( 1 0 '3 — Y <br /> /� nerl.P r.,ie i ure Date (Revised 10/10/ 018) <br />