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PLANNING, COMMUNITY, & EC0NOMIC DEVELOPMENT DEPARTMENT <br /> ' Mailing A��ess: P.O, Box 54 7Ana[ortes, WA 98221 <br /> ' '^ ~ OV9�ceLoco�on: 9O4 #1 Street, N/ <br /> �noCortesA98822 <br /> '~ <br /> P607e: (360 �13'1902 <br /> ' <br /> 6� LENDER INFORMATION <br /> RCVVz9.27.095/requires the City to obtain information with regard to lenders. If there are no lenders involved with your project, <br /> write"no lenders"on the Name Line below. � <br /> Name� �/ Phone: <br /> � No lenders | <br /> Address_`_--`City,State,--': <br /> Email Address: <br /> 7^ ACKNOWLEDGEMENTS & SIGNATURE <br /> | <br /> Read and initial each of the following statements priorto signing this application: <br /> | <br /> ! I understand that when a building permit application is taken in over the counter it does not mean <br /> the application has been deemed technically complete and sufficient for staff review. <br /> | understand that dlsubmit incomplete,\ncn inaccurate,and/or erroneous information it will take the <br /> City longer to process my permits. <br /> I understand and acknowledge that I could be responsible for providing as-built drawings(on paper <br /> or electronically)as part of the project's certificate uf occupancy process. <br /> I understand and acknowledge that Special Inspections could be required as part of my project, and <br /> if needed (will be required to pay for the cost of these inspections. <br /> ' I understand and acknowledge that financial securities could be required as part of the work I am ' <br /> � L-K completing and 1 agree to provide the items needed for the City to calculate these securities and tn <br /> provide the securities themselves. <br /> I understand that if permits are reviewed concurrently such as design review, site plan,traffic <br /> L�, concurrency,etc., any required revisions to one permit may affect the entire plan set and could <br /> add costs and time to the project. <br /> I hereby declare that I am either the owner of the property listed on this application or the owner of <br /> this property has authorized me to be their representative to act for them. \ also declare under <br /> penalty of perjury underthe |avxooftheState0fVVaohinQtonthata\|nfthestatenmentoandansvvery <br /> contained herein,and the information submitted with this application form is in all respects, true, <br /> � correct, and complete to the best of knowledge and belief, <br /> �0 ~~^� <br /> Signature <br /> � � �,��� _ ,[ate� <br /> -�~^ <br /> � ` ` ' - - <br /> / -- ^^~-._ �^ ^ <br /> � Printed Name <br /> Res.Building Permit Application Submittal <br /> Cmeomoz _ <br /> Updated^"October~°~~^� �' - - <br /> Page 6of18 <br />