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�• G PERMIT APPLICATIC'" EVEOVIE <br /> B1111 IFiI <br /> CITY OF EVERETT PERMIT SERVICES i . <br /> EVERETT SUBMITTAL INSTRUCTIONS: See applicable submittal checklist for submittal requirements and number of copies requlirM for review, <br /> WASHINGTON then drop off completed application plus all required submittal documents to 3200Cedar <br /> Street n Floor <br /> ermits Intake Drop Box. <br /> CONTACT INFORMATION: (P)425-257-8810 1(E)PermitServices@everettwa.gov <br /> ov (W) .9 P <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> r'O':'T1't s r ' c' <br /> PROJECT SITE ADDRESS: STREET 4512 Forest Drive <br /> PARCEL#: 00449400200900 <br /> CIn, Everett STATE <br /> WA ZIP 98203 <br /> SUITE/UNIT#: FLOOR#: <br /> ADDITIONAL LOCATION INFORMATION (if applicable): <br /> TENANT/BUSINESS NAME(if non-residential):AT&T <br /> LEGAL DESCRIPTION for new construction: Short Plat/subdivision: <br /> Lot No.: (attach copy of long legal description) <br /> CONTACT INFORMATION <br /> OWNER NAME:Public Utility District#i Sno Co <br /> OWNER MAILING ADDRESS: STREET 2320 California St <br /> Everett STATE <br /> WA ZIP 98201 <br /> clrY <br /> OWNER EMAIL: <br /> OWNER PHONE: o 4,44 <br /> e at time o pe <br /> CONTRACTOR COMPANY NAME:TBD:�eie 'L�Li ? <br /> '� c�7 �CIT�1'OF EVERETT BUSINESS LICENSE#(REQUIRED): � Y <br /> WA STATE CONTRACTOR LICENSE#(REQU�IRED)• / — �G�` <br /> CONTRACTOR ADDRESS: STREET .� ZIP <br /> /�� 1•f STATE `�� <br /> CITY ( V � <br /> CONTRACTOR PHONE: C, - <br /> CONTRACTOR EMAIL: /I/!il`c-C7 �, PS� <br /> PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR ©OTHER(Please Specify) Agent <br /> CONTACT PHONE:206-372-5155 <br /> CONTACT NAME: <br /> u Chang CONTACT EMAIL:Fchang@rykaconsulting.com <br /> BUILDING INFORMATION <br /> $2 ASSOCIATED LAND USE PROJECT#(if,applicable): <br /> VALUATION OF WORK: 5,000.00 <br /> (Valuation shall include the prevailing fair market value of all labor,materials,and equipment needed to comple t work,whether ctually paid or not.) <br /> e the a <br /> EXISTING USE OF BUILDING: <br /> PROPOSED USE OF BUILDING: <br /> HEAT SOURCE: []Gas ❑Electric ❑Other ©Commercial (]Accessory Structure <br /> BUILDING TYPE: ❑SFR [] wnhouse ❑Duplex DADU ❑Multi-Family-#Units: <br /> TYPE OF PROJECT(check all that apply): ❑New Construction DAddition ❑Remodel ❑Repair OT.I. ❑Change of Use <br /> ❑Modular []Portable []Re-roof ❑Exterior Alteration ElTank(above ground) DAccessory Structure <br /> El Fence over 7ft high ❑RackStorage ❑Pool/Hot Tub Tank(above ground) <br /> ✓Other:Replace 3 antennas on the rooftop <br /> g of 6 antennas by <br /> DESCRIPTION OF WORK:AT&T proposes to modify wireless communication facility consistin <br /> replacing 6 antennas with 9 new antennas. No changes in height proposed. No <br /> changes to the number of equipment cabinet proposed. <br /> rk done <br /> to <br /> s permit must <br /> ly with <br /> ACKNOWLEDGEMENT:I have reviewed poI f atpermi only authion and confirm torizes approved work he information nand ned eo deviations therefrom.Derein is true and correct. viations must first te author ed n writing from the <br /> current federal,state,and local law. The granting to erform the work for which application is made, <br /> Building Official before being authorized under any circumstance.I am the owner,or I am authorized by the owner of this property City <br /> ty of Everett Official Use Only <br /> and/comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> PE=12022) <br /> ��� � <br /> F u Chang Digitally signed by Fu Chang 5/1 8/23 <br /> Date:2023.02.1412:31:42 08'00' <br /> Owner/Authorized Agent Signature <br /> Date <br />