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11 <br /> PLUMBING PERMIT APPLICATION <br /> EVERETT SUBMITTAL INSTRUCTIONS: <br /> OF EVERETT PERMIT SERVICES <br /> S: 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)PermitServices@everettwa.gov I(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET 3414 Nassau PARCEL#: <br /> cn-Y Everett STATE WA ZIP 98201 <br /> SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION: <br /> TENANT/BUSINESS NAME(if non-residential): <br /> CONTACT INFORMATION <br /> OWNER NAME:Pam Gerla <br /> OWNER MAILING ADDRESS: sTREET3414 Nassau ST <br /> c,n Everett STATE WA zip 98201 <br /> OWNER PHONE:(425) 359-6221 OWNER EMAIL: <br /> CONTRACTOR COMPANY NAME:Eckerson Construction Inc <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED):ECKERC1975RB CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): 051249 <br /> CONTRACTOR ADDRESS: STREET5005A 109th ST NE <br /> CITY Marysville STATE WA zip 98271 <br /> CONTRACTOR PHONE:(425) 330-6022 CONTRACTOR EMAIL:meconstruction@frontier.com <br /> PRIMARY CONTACT: ❑OWNER i]CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE:(425)330-6022 <br /> Matt CONTACT EMAIL:meconstruction@frontier.com <br /> PLUMBING PERMIT INFORMATION <br /> VALUATION OF WORK:$40,000 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:moving laundry to main floor and adding an additional bathroom to existing floorspace. <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: t Shower,Tub,or Combo <br /> Fire Service:❑DCDA, Domestic Service:❑RPBA EDCVA Commercial Sink(3-compartment,prep,floor) <br /> t Clothes Washer t Residential Sink(kitchen,bath,bar) _ <br /> Dishwasher Utility Sink(laundry,mop) <br /> Drinking Fountain t 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 /> Ind Cv--"L_ 6/9/22 PERMIT# ®� ! L <br /> Owner/Authorized Agent Signature Date (Revised 4/21/2022) <br />