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y PLANNING, COMMUNITY, &ECONOMIC DEVELOPMENT DEPARTMENT <br /> 0 <br /> -` RE-ROOF PERMIT APPLICATION <br /> Mailing Address:P.O. Box 547, Anacortes, WA 98221 <br /> i' ` Office Location: 904 6`h Street, Anacortes WA 98821 <br /> Phone: (360) 293-1901, Fax: (360) 293-1938 <br /> PLEASE REFER TO THE RE-ROOF PERMIT CHECKLIST FOR SUBMITTAL REQUIREMENY'S <br /> XRESIDENTIAL 0 COMMERCIAL <br /> PROJECT ADDRESS(Street,Suite#): PARCEL(s)#: <br /> /S>zi <br /> Subdivision/Lot#: PROJECT VALUATION$ <br /> ol APPLICANT: Phone: 7 / a <br /> 2 Yy 7 <br /> Address(Street,City,State,Zip): E-Mail Address: <br /> PROPERTY OWNER: G Phone: <br /> A-`'/i) � o Z.93 2yy7 <br /> Address(Street,City State,Zip)• E-Mail Address: <br /> 3�// / '/,Gs 1/4-j <br /> CONTACT PERSON: Phone: <br /> Address(Street,City,State,Zip): E-Mail Address: <br /> —z /( s <br /> CONTRACTOR:* Phone: <br /> Address(Street,City,State,Zip): E-Mail Address <br /> *All Contractors&subcontractors must have a valid City of Contractor's License# Exp.Date: <br /> Anacortes business license prior to doing work in the City. Business License#: Exp.Date: <br /> Contact the City's Finance Department at(360)299-1968. <br /> PROPOSED WORK: f&' A o U/G <br /> TYPE OF ROOFING: co M( NUMBER OF LAYERS: <br /> CLASS OF ROOFING: ❑ A ❑ B ❑ C NUMBER OF SQUARES: 3 <br /> I declare under penalty of perjury that the information I have provided on this form/application is true, correct,and <br /> complete,and that I am the property owner or duly authorized agent of the property owner to submit a permit <br /> application to the City of Anacortes. <br /> Print Name: p .�v t 60-7 Owner,Other 0 (specify): <br /> Signature: [�Lu�L.' (//l 6-Q7 Date: F` Z— 2 / <br /> Page 1 of 2 <br />