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<br /> PLANNING COMMUNITY, & ECONOMIC DEVELOPMENT DEPARTMENT
<br /> �', "' PLUMBING & MECHANICAL PERMIT APPLICATION
<br /> " ,; ;.;. Mailing Address: P.O. Box. 547, Anacortes, WA 98221
<br /> 1 ar, ' Once Location: 904 6111 Street., Anacortes WA 98821 '
<br /> Phone: (360) 293-1901, Fax: (360) 293-1938
<br /> PLEASE REFER TO THE PLUMBING & MECHANICAL PERMIT CHECKLIST FOR SUBMITTAL REQUIREMENTS
<br /> PROJECT ADDRESS (Street, Suite #): . Parcel(s) #:
<br /> Q--3 i C.- Cl- i - r -7
<br /> Subdivision/Lot#: r
<br /> `-Ct S Residential Commercial 0
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<br /> APPLICANT: r Phone: Fax:
<br /> �05S (,, A-.,; -Fcep 33 t 7
<br /> Address Stree City, State,.Zip): /-c.± Vc v o►-1 E-MailAddress:
<br /> '3�3 i cv -�.‘C`0 id,r (I A cr.t- `11 l 3 alCX �'' � Lam ., --/1 ,> - ,
<br /> PROPERTY OWNER: Phone: Fax:
<br /> `j-6,c rr Alb C - �t-L c-- d C 3 7 2- E 8 t`f
<br /> Address (Street, City, State, Zip): Al, 4 E-Mail Address:
<br /> -4_-7 i 62 \2 ti-c — CI. 7 2--7-1 C.Gc..e..1,C) ti o roll k. Q C`q. 4- -cam-' I C c-p,..t
<br /> CONTACT:PERSON: ( Phone: Fax: ✓
<br /> c,c/c.A.4-.4 /vc,Y-obt- t,A-
<br /> Address (Street, City, State,.Zip): E-Mail Address:
<br /> CONTRACTOR:* Phone: Fax:
<br /> fe 5-5 tL,,c -z--)1-1i,.,
<br /> Address (Street, City, State, Zip): E-Mail Address
<br /> Contractor's License
<br /> Exp. . ate:
<br /> *All Contractors & subcontractors must have a valid City of -�.5.� �c ( f
<br /> � �Z `� 1� r F'
<br /> Anacortes business license prior to doing work in the Citta. Business License#: Exp. ate:
<br /> Contact the City's Finance Department at(360) 299-1968. r 07 t ( I / / 17
<br /> Is this work, associated with another project? Yes 0 No 10 If yes, specify:
<br /> PROPOSED WORK:
<br /> e_c c�. ,( •mot,G.t.� y I�, '
<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 A acortes.
<br /> Print Name: V L., jn.G^e-% Owner t3,.A en (specify): c v t- Lc ck
<br /> Signature: L �- Date: t o. ci (I
<br />
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