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PLUMBING E MIT APPLICATION <br /> EVERETT CITY OF EVERETT PERMIT SERVICES <br /> SUBMITTAL INSTRUCTIONS: Drop off hard copy completed paper application to 3200 Cedar Street 2nd Floor Intake Drop Box. <br /> WASHINGTON CONTACT INFORMATION: (P)425.257.8810 1(E)everetteps@everettwa.gov I(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET 1 dS7 I { tf- PARCEL#: <br /> CITY S�VL'f�•#-+— STATE y� ZIP <br /> SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFOR ATION: <br /> TENANT/BUSINESS NAME (if non-residential): 61 J #ATAIecect { CC " r i�ciUrah C u,C <br /> I CONTACT INFORMATION <br /> OWNER NAME: y` �'Y��� I©� -o <br /> tyn <br /> OWNER MAILING ADDRESS: STREET 2D3go it <br /> 5ltvtC�dC �,� M_ Jc�s3 <br /> CITY �,�itn �� STATE W 0 ft zip Cl V 2, <br /> OWNER P yq® q EMAIL: qdYlA41G Ibr '(q c O'rcX hJl'1 I u Cd M'! <br /> CONTRACTOR COMPANY NAME: <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): <br /> CONTRACTOR ADDRESS: STREET <br /> CITY <br /> STATE zip <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> PRIMARY CONTACT: OWNER ❑CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: <br /> CONTACT EMAIL: <br /> PLUMBING PERMIT INFORMATION <br /> VALUATION OF WORK: $ y®,Q® ASSOCIATED PERMIT#(if applicable): <br /> (Valuation shall include the prevailing fair market value of all labor,materials,and equipment needed to complete the work,whether actually paid or not.) <br /> BUILDING TYPE: ❑SFR ❑Townhouse ❑Duplex ❑ADU ❑Multi-Family-#Units: ®Commercial ❑Accessory Structure <br /> DESCRIPTION OF WORK: . (u{+®� <br /> �wsTcht,v► ®f ��� 5�hi�� , Or�� far t,U05hing eta s s,�'�1.��a. of Ap_ <br /> (� Stunt. ct�al P[t(i } © �I�tikm� pf asiA�. )hfi ate of~ 1�� r cly vY,ls� 10 <br /> PLUMBING'PERMIT FIXTURE COUNT(SCOPE OF WORK) <br /> Fixture Fixture <br /> Count List of Fixtures Count List of Fixtures <br /> (QtY) (QtY) <br /> Backflow Prevention Device(Inside Building)-select devices below: Shower,Tub,or Combo <br /> Fire Service:❑DCDA, Domestic Service:❑RPBA❑DCVA Commercial Sink(3-compartment,prep,floor) <br /> Clothes Washer I Residential Sink(kitchp4 bath, a <br /> Dishwasher I Utility Sink(laundry,mop) <br /> Drinking Fountain Toilet <br /> Floor Drain Urinal <br /> Hose Bibb Waste/Water Pipe Repair <br /> Ice Maker Water Service Line(Behind meter,private side) <br /> Grease Interceptor Water Valves/Fixtures <br /> Sand/Oil Interceptor Water Heater-Electric <br /> Medical Gas Water Heater-Gas <br /> Roof Drains Other(List Type): <br /> Sewage Ejector Pump/Sump Pump Other(List Type): <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 /> PERMIT# <br /> Owner/Authorized Agent Signature Date (Revised 21812021) <br />