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PLUMBING PERMIT APPLICATION <br />EVERETT <br />WASHINGTON <br />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 />CONTACT INFORMATION: (P) 425.257.8810 1 (E) everelteps@everettwa.gov I (W) everettwa.gov/permits <br />(Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br />PROJECT SITE ADDRESS: STREET 4919 Evergreen Way PARCEL #: 0058100000101 <br />ciw Everett STATE WA zip 98201 <br />SUITE/UNIT #: FLOOR M ADDITIONAL LOCATION INFORMATION: <br />TENANTIBUSINESS NAME (if non-residential): QFC-Quality Food Center <br />CONTACT INFORMATION <br />OWNER NAME: Claremont Village Station LLC <br />OWNER MAILING ADDRESS: STREET 11501 Northlake Drive <br />CIT'r Cincinnati STATE OH zip 45249 <br />OWNER PHONE: (206) 808-0303 <br />OWNER EMAIL: brian.peterson@kroger.com <br />CONTRACTOR COMPANY NAME: TO be determined <br />WA STATE CONTRACTOR LICENSE #(REQUIRED): <br />CITY OF EVERETT BUSINESS LICENSE #(REQUIRED): <br />CONTRACTOR ADDRESS: STREET <br />cIW STATE Zip <br />CONTRACTOR PHONE: <br />CONTRACTOR EMAIL: <br />PRIMARY CONTACT: 1-1OWNEREl CONTRACTOR CXOTHER (Please Specify) Barghausen Consulting Engineers, Inc. <br />CONTACT NAME: CONTACT PHONE: (425) 251-6222 <br />Joel HOwitt CONTACT EMAIL: 'howitt�a barghaUSeO.com <br />PLUMBING PERMIT INFORMATION <br />VALUATION OF WORK: $ 10,000 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: IIMCommercial ❑Accessory Structure <br />DESCRIPTION OF WORK: Install plumbing connections for new cashier's kiosk with single uni-sex employee restroom as part <br />of new retail fueling station. <br />PLUMBING PERMIT FIXTURE COUNT (SCOPE OF WORK) <br />Fixture <br />Count <br />(Qty) <br />List of Fixtures <br />Fixture <br />Count <br />(Qty) <br />List of Fixtures <br />Backflow Prevention Device (Inside Building) -select devices below: <br />Fire Service: ❑DCDA, Domestic Service: ❑RPBA ❑DCVA <br />Shower, Tub, or Combo <br />omm <br />Commercial Sink (3-compartment, prep, floor) <br />Clothes Washer <br />I Residential Sink (kitchen, bath, bar) <br />Dishwasher <br />2 <br />Utility Sink (laundry, mop) <br />Drinking Fountain <br />1 <br />Toilet <br />1 <br />Floor Drain <br />Urinal <br />Hose Bibb <br />WasteiWater Pipe Repair <br />Ice Maker <br />Water Service Line (Behind meter, private side) <br />Grease Interceptor <br />Water Valves/Fixtures <br />1 <br />Sand/Oil Interceptor <br />Water Heater - Electric <br />Medical Gas <br />Water Heater - Gas <br />Roof Drains <br />Other (List Type): <br />Sewage Ejector Pump/Sump Pump <br />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 he 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 />8/24/2021 PERMIT # 1 <br />0 O <br />Owner/Authorized Agent Signature Date (Revised 218/20211 <br />