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PERMIT APPLICATION <br /> BUILDING / MECHANICAL/ PLUMBING /SIGN /SPRINKLER/ DEMOLITION <br /> Nitia J 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: 1919 112th St S W PROPERTY TAX#:0 05-13 7C0 t ft . <br /> LEGAL for new construction: Short Plat/subdivision Lot No. (attach copy of long legal description) <br /> CONTACT INFORMATION <br /> OWNER NAME: Everett Rehab and Medical TENANT NAME(If Commercial): NATION HEALTH PROPERTIES <br /> OWNER MAILING ADDRESS: STREET 18818 TELLER AVE STE 277 <br /> CITY IRVINE STATE CA ZIP 92612 <br /> OWNER PHONE: 425-265-7710 OWNER EMAIL: BARRY.KRIEWALD@GENISISHCC.COM <br /> CONTRACTOR NAME: D SQUARE ENERGY LLC <br /> CONTRACTOR ADDRESS: STREET 201 W NORTH BEND WAY <br /> CITY NORTH BEND STATE WA ZIP 98045 <br /> CONTRACTOR PHONE: 206-947-1535 CONTRACTOR EMAIL: keithj@d2energy.com <br /> CONTRACTOR LICENSE#(REQUIRED): DSQUASE895DQ CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): ZZ3 <br /> PRIMARY CONTACT: 0 OWNER CONTRACTOR 0 OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: 206-947-1535 <br /> KEITH JONES CONTACT EMAIL: <br /> keithj@d2energy.com <br /> BUILDING PERMIT APPLICATION <br /> Existing Use of Building:NURSING HOME Contract Price of Work:$ 100.00 <br /> Proposed Use of Building:SAME Heat Source: ❑Gas DElectric POther Existing Concrete Pad <br /> Building Type: ❑SFR-Detached DSFR-Attached ❑Duplex DMulti-Family-#of Units: PCommercial ❑Industrial <br /> Type of Project: ❑New DAddition ❑Remodel DRepair 0T.l. DSign ❑Sprinkler ❑Demolition OChange of Use <br /> DESCRIPTION OF WORK: <br /> EXISTING CONCRETE PAD , NEEDS NEW PERMIT , OLD PERMIT # B44582 <br /> ASSOCIATED BUILDING PERMIT#(if applicable): <br /> MECHANICAL PERMIT APPLICATION PLUMBING PERMIT APPLICATION <br /> Type of Project: New Addn _Alteration Repair Type of Project: _New Addn _Alteration Repair <br /> #of #of <br /> Fixtures List of Fixtures Fixtures List of Fixtures #of List of Fixtures #of List of Fixtures <br /> 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 /> Chemical or Water I INo.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# <br /> Owner/Author' d Agent Signature Date <br /> (Revised 9/23/2016) <br /> z- <br />