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BUILDING PERMIT APPLICATION <br /> EVERETT CITY OF EVERETT PERMIT SERVICES <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)PermitServices@everettwa.gov I(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET 5?I 7 � r'X,*'-- PARCEL M <br /> CITY _ STATE lWA ZIP <br /> SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION (if applicable): <br /> TENANT/BUSINESS NAME(if non-residential): <br /> LEGAL DESCRIPTION for new construction: Short Plattsubdivision: Lot No.: (attach copy of long legal description) <br /> CONTACT INFORMATION <br /> OWNER NAME: e -7 Lt <br /> OWNER MAILING ADDRESS: STREET "J ( <br /> CITY ed STATE PV06ZIP <br /> OWNER PHONE: V(O% —Z! : OWNER EMAIL: L <br /> CONTRACTOR COMPANY NAME: tic <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): CITY OF EVERETT BUSINESS LCENPC �l <br /> CONTRACTOR ADDRESS: STREET <br /> CITY STATE P2 4 2024 >� <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> PRIMARY CONTACT: WWNER ❑CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: M/ CONTACT PHONE: <br /> CONTACT EMAIL: <br /> BUILDING INFORMATION <br /> VALUATION OF WORK:$ y ASSOCIATED LAND USE PROJECT#(if applicable): <br /> (Valuation shall include the prevailing fair markkett�value of all labor,"materials,and equipmenttnnee`ded to complete the work,whether actually paid or not.) <br /> EXISTING USE OF BUILDING: <br /> PROPOSED USE OF BUILDING: LV <br /> HEAT SOURCE: ❑Gas M(Qlectric ❑Other <br /> BUILDING TYPE: �GSFR []Townhouse []Duplex ❑ADU ❑Multi-Family-#Units: ❑Commercial ❑Accessory Structure <br /> TYPE OF PROJECT(check all that apply): El New Construction ❑Addition Wemodel ❑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: <br /> DESCRIPTION OF WORK: <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 /> m r �4,2 PERMIT# �� <br /> Owner/Ruth d Agent Signature Date (Revised 412112022) <br />