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131 "'_DING PERMIT APPLICAT")N <br /> CITY OF EVERETT PERMIT SERVICES <br /> EVERETT <br /> SUBMITTAL INSTRUCTIONS:See applicable submittal checklist for submittal requirements and number of copies required for review, <br /> WASHINGTON then drop off completed application plus all required submittal documents to 3200 Cedar Street 2nd Floor Intake Drop Box. <br /> CONTACT INFORMATION: (P)425-257-8810 1(E)PermitServiceseeverettwa.gov I(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET L b PARCEL#: 005 LVO QQLAQ I r D <br /> STATE ZIP e�"s ' ,y <br /> CITY <br /> SUITE/UNIT#: ti)A FLOOR M 'Q; ,A ADDITIONAL LOCATION INFORMATION (if applicable): <br /> TENANT/BUSINESS NAME(if non-residential): 01 iA <br /> LEGAL DESCRIPTION for new construction: Short Plat/subdivision: )"� Lot No.: (attach copy of long legal description) <br /> CONTACT INFORMATION <br /> OWNER NAME: I'll, <br /> OWNER MAILING ADDRESS: STREET `) <br /> CITY �� Q-ft STATE W��h ZIP 2$2D.3 <br /> OWNER PHONE: L�' �� OWNER EMAIL: I i fIR s 1 7 <br /> CONTRACTOR COMPANY NAME: \ + I <br /> WA STATE CONTRACTOR LICENSE#(R EQUIREDYW55R90116 HI CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): <br /> CONTRACTOR ADDRESS: STREET C SLo' c C <br /> CITY Q�9._ STATE ZIP /k V <br /> CONTRACTOR PHONE: i121 - Z Ll <br /> CONTRACTOR EMAIL: 1 <br /> PRIMARY CONTACT: ❑OWNER CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: 92 - 9 <br /> (,•• (� hI V Y�\� _�O n CONTACT EMAIL: L�� tL . NVy <br /> BUILDING INFORMATION <br /> VALUATION OF WORK: $ ,21j ASSOCIATED LAND USE PROJECT#(if applica ` <br /> (Valuation shall include the prevailing fair marke value of all labor,materials,and equipment needed to complete the work,whother actually paid or not. <br /> EXISTING USE OF BUILDING: F }' <br /> PROPOSED USE OF BUILDING: �r <br /> HEAT SOURCE: ❑Gas ❑Electric ❑Other t 1In CITY OF EVFRFTT <br /> BUILDING TYPE: GSFR ❑Townhouse ❑Duplex ❑ADU ❑Multi-Family-#Units: ❑Commercial (P, �br$ervitimS <br /> TYPE OF PROJECT(check all that apply): ❑New Construction ❑Addition ❑Remodel ❑Repair ❑T.I. ❑Change of Use <br /> []Modular ❑Portable ❑Re-roof ❑Exterior Alteration ❑Tank(above ground) ❑Accessory Structure <br /> ❑Fence over 7ft high ❑RackStorage ❑Pool/Hot Tub ❑Tank(above ground) ❑Other: Eiii.lo i ns- 9u,4`•r,-A li{� <br /> DESCRIPTION OF WORK: <br /> e.(kz0,I -ki <N1 +�-1 0 C X 1,j i^ A A CG"-Q. YayQ:A <br /> - " (OnQQ <br /> '2-" .�,, —; Ak c- 4 vas-A km 1-(,q <br /> \J <br /> ACKNOWLEDGEMENT:1 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.1 am the owner,or 1 am authorized by the owner of this property to perform the work for which application is made, <br /> and 1 comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> PERMIT# �2404 <br /> Owner/Authorized Agent Signature Date (Revised 412112022) <br />