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II IIII''II II PERMIT APPLICAI#JII <br /> /1111P4147-1 <br /> BUILUIRG /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 /> (Blue:or Black ii ik OnlyPleas i <br /> PROIEC'f SITS iNFORI(lIATION , ,,mta `; ,,,i„ r <br /> PROJECT SITE ADDRESS:LI' J + 2927 Rockefeller Ave PROPERTY TAX#: 004" 00300+00439168500402 <br /> LEGAL for new construction: Short <br /> Plat/subdivision Lot No. (attach copy of long legal description) <br /> ,,, CONTACT INFORMATION <br /> OWNER NAME: Snohomish County TENANT NAME(If Commercial): N/A-Abandoned <br /> OWNER MAILING ADDRESS: STREET 3000 Rockefeller Ave; M/S 404 <br /> CITY Everett STATE WA ZIP 98201 <br /> OWNER PHONE: 425-388-3154 OWNER EMAIL: Jeffery.Hencz@co.snohomish.wa.us <br /> CONTRACTOR NAME: FORMA Construction Co. <br /> CONTRACTOR ADDRESS: STREET PO Box 11489 <br /> CITY Olympia STATE WA ZIP 98508 <br /> CONTRACTOR PHONE: (206)626-0256 CONTRACTOR EMAIL: LoriN@formacc.com <br /> CONTRACTOR LICENSE#(REQUIRED): FORMACC878OR CITY OF EVERETT BUSINESS LICENSE#(REQUIRED):054396 <br /> PRIMARY CONTACT: 0 OWNER gi CONTRACTOR 0 OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: (206)475-0792 <br /> Lori Nicholson CONTACT EMAIL:LoriN@formacc.com <br /> glIMIffignaWatiflinitlrigaiAtiggAMEWILL)INGORERMITAPPLICATIONYMMUMMT-WiiiiititiffgraligiftW5 <br /> Existing Use of Building: Abandoned Commercial Contract Price of Work:$ 1 19, 9.54 S9 �a$ A. <br /> Proposed Use of Building: Demolition Heat Source: OGas ❑Electric ❑Other <br /> Building Type: ❑SFR-Detached ❑SFR-Attached ❑Duplex ❑Multi-Family-#of Units: ZCommercial ❑Industrial <br /> Type of Project: ❑New DAddition ❑Remodel ❑Repair ❑T.I. ❑Sign ❑Sprinkler 4nDemolition ❑Change of Use <br /> DESCRIPTION OF WORK: <br /> Demolish building in its entirety; provide compacted fill at demo sites; existing grades and drainage to be unchanged <br /> ASSOCIATED BUILDING PERMIT#(if applicable): <br /> MECHANICAL PERMIT APPLICATION,':- r .: , PLUMBING PERMIT,APPLICATION <br /> Type of Project: _New _ Addn _Alteration _Repair Type of Project: New Addn _Alteration _Repair <br /> #ofList of Fixtures #of List of Fixtures #of List of Fixtures #of List of Fixtures <br /> Fixtures Fixtures Fixtures Fixtures <br /> A/C—Air Handling Units 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 /> SPRINKLER ,SUPPRESSION SYSTEM< , <br /> !Number 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 /> M�TCity of Everett Official Use Only <br /> 42 0/11018 P 201$ 6 27_61)3 <br /> Owner/Authorized Agent Signature Date (Revised 9/23/2016) <br /> 61D <br />