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1 <br /> E <br /> PLLMBING PERMIT APPLICATION <br /> EVERETT SUBMITTAL CITY OF EVERETT PERMIT SERVICES <br /> 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 I(E)everetteps@everettwa.gov I(W)everettwa.gov/permits <br /> (Blue.or Black Ink Only Please) PROJECT fete' <br /> E INFORMATION <br /> PROJECT SITE ADDRESS: STREET 1 -2,0 0 fe J ' PARCEL#:CITY STATE t J���fff <br /> '/ ZIP <br /> SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION: <br /> TENANT/BUSINESS NAME(if non-residential): <br /> CONTACT INFORMATION <br /> OWNER NAME: ll 'V Y L 0! 9-(/ O,ei <br /> OWNER MAILING ADDRESS: STREET 1,tQ r 1 F I u t �` ///' <br /> CITY STATE Y- ` ZIP led e l b L <br /> OWNER PHONE: (4,,` j p .,I`e Cj ‘ OWNER EMAIL: etu , 0 i �A-�}/ ,e(/��( <br /> CONTRACTOR COMPANY NAME: V J <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): <br /> CONTRACTOR ADDRESS: STREET <br /> CITY STATE ZIP <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> , <br /> PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE:VV LI .311. a� �� <br /> r1�k1 owts-� CONTACT EMAIL: 4v � ymcCe,,v)0P ?v. o <br /> PLUMBING PERMIT INFORMATION <br /> VALUATION OF WORK:$ 11 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 ElDuplex ❑ADU ❑Multi-Family-#Units: ❑Commercial ❑Accessory Structure <br /> DESCRIPTION OF WORK: <br /> Nkouct t QUdt_vv- aLPy ke) aw) <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 Residential Sink(kitchen,bath,bar) <br /> Dishwasher 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:1 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 1 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 /> p (f City of Everett Official Use <br /> Only <br /> 121\ YI 1 '/"7) PERMI E\ \ ze, „Q2 <br /> Own Authorized Agent Signature Date (Revised 2/8/2021) <br />