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d . ei:51ki-, d,,,,_)%r <br /> 2 PLBING PERMIT APPLICAT <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 I(E)everetteps@everettwa.gov I(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITEADDRESS: STREET 9/o ,L N�^5 I0,�d(j✓/b/ PARCEL#: aZ.�7 V.10 AZ.'I 700.A01/D d J <br /> // V G/` / f CITY (�^V et? err STATE u.'-/!/ii zip �j�/-siC) <br /> SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION: <br /> TENANT/BUS AME(if non-residential): et/CI > rWlvi i Ly //4'0 021(wf " v. "frit L LC <br /> / CONTACT INFORMATION y_12.FLVVAN (' fhF <br /> OWNER NAME: tJ e.Ae mi' A 1,06 i L4-''td <br /> OWNER MAILING ADDRESS: STREET ?23 / ig&c,Iotia L #1,R <br /> CITY gU(vn.((/ cam STATE 1/4'0- _ ZIP q$O.0 I <br /> OWNER PHONE: ;to 6 -7 3 3 D Lela OWNER EMAIL: 611 A tl tin 1i' 9 in Ail. A- C.;o ill <br /> CONTRACTOR COMPANY NAME: 0-714 L f'0 i (...sCL SL, J ( <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): 3?IJ< �I <br /> CONTRACTOR ADDRESS: STREET ail f/ /� ,f q q , ',cif- 6CITY /` went U STATE Lir-9,- ZIP c7 g A o <br /> CONTRACTOR PHONE: Ric- -7�� ,/o 6,6....C1) <br /> ' CONTRACTOR EMAIL: //r/�O 6 JOiibCo✓t,f cri.0 l c C�',R <br /> PRIMARY CONTACT: El OWNER I 'C//ONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: a 0 (,- 2_3,c lei <br /> 1742A/l �1"`viy2,JQ f _CONTACT EMAIL:/#4,/ro 0 0E4Ct"4 St/Ul Cs/74.).0 4. CON/ <br /> PLUMBING PERMIT INFORMATION <br /> VALUATION OF WORK:$ 2 jJ ®o o t O'`� ASSOCIATED PERMIT#(if applicable): pw20L0 ^ o2-4. <br /> (Valuation shall include the prevailing fair market value of at labor,materials,and equipment needed to complete the work,whether actually paid or not.) <br /> BUILDING TYPE: ❑SFR ❑Townhouse ❑Duplex ❑ADU ❑Multi-Family-#Units: Ieo'mmercial ❑Accessory Structure <br /> DESCRIPTION OF WORK: NGU RDA Iia i/twi ) A mop Sint-act Kart ,ell sb"`I 'n ✓-,-4h.l � 44-- t - 4.12c; <br /> f 0A- <br /> PLUMBING PERMIT FIXTURE COUNT (SCOPE OF WORK) <br /> Fixture Fixture <br /> Count List of Fixtures Count List of Fixtures <br /> (Qtv) (Qty) <br /> Backflow Prevention Device(Inside Building)-select devices below: Shower,Tub,or Combo <br /> re Service:❑DCDA, Domestic Service:❑RPBA❑DCVA / Commercial Sink(3-compartment,prep,floor) <br /> Aothes Washer Residential Sink(kitchen,bath,bar) <br /> _ —Dishwasher / Utility Sink(laundry,mop) <br /> / Drinking Fount n / Toilet <br /> Floor Drain Urinal <br /> Hose Bibb Waste/Water Pipe Repair <br /> lce Maker411 <br /> 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 properly to perform the work for which application is made, <br /> and I comply with the State Contractors Law 18.27 RCW and 298.200A WAC. <br /> City of Everett Official Use Only <br /> �1 Io , 3/9 P k 0 ©2 , <br /> wnerlAuthon� tSignature Date (Revised 2/8/2021) <br />