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r• <br />EVERETT <br />WASHINGTON <br />PLUMBING PERMIT APPLICATION <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) everetteps@everettwa.gov I (W) everettwa.gov/permits <br />(Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br />PROJECT SITE ADDRESS: srReEr jj JeV& RCEL#:: aL? �f 0; 7�U � <br />ppO <br />CITY �j�✓e�Ci� STATE "W/A ZIP 1&2-_> l <br />SUITE/UNIT #: FLOOR #: ADDITIONAL LOCATION INFORMATION: <br />TENANT/BUSINESS NAME (if non-residential): <br />CONTACT <br />OWNER NAME: u 1 /`� <br />/INFORMATION <br />(�{Q I C.// ,A/&/I 6 V( V-( <br />OWNER MAILING ADDRESS: STREET % (pt7 94 /rVL 5'�L <br />CITY STATE ZIP O C% <br />OWNER PHONE: <br />OWNER EMAIL: <br />I1 <br />CONTRACTOR COMPANY NAME: W� D Zvi <br />WA STATE CONTRACTOR LICENSE #(REQUIRED): lJ W�� <br />OF EVERETT BUSINESS LICENSE #(REQUIRED): 3 <br />'/0I <br />CONTRACTOR ADDRESS: STREET <br />/ <br />CITY STATE W 4 ZIP J <br />CONTRACTOR PHONE: ZO <br />CONTRACTOR EMAIL: <br />PRIMARY CONTACT: ❑ OWNER CONTRACTOR ❑ OTHER (Please Specify) <br />CONTACT NAME: - L I <br />DLL`► <br />CONTACT PHONE: Zp <br />CONTACT EMAIL: rj(' otjG( ctivVl �j, LYit <br />PLUMBING PERMIT INFORMATION <br />VALUATION OF WORK: $ 73—vo 1 <br />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: VJSFR ❑Townhousse QDuplex ❑ADU ❑Multi -Family - # Units: ❑Commercial ❑Accessory Structure <br />DESCRIPTION OF WORK: �\Aqa �1 GGL✓t t �etil'� ,WV( tAJA_ttr I�II9� +� � b�t�h r, <br />PLUMBING PERMIT FIXTURE <br />COUNT (SCOPE OF WORK) <br />Fixture <br />Count <br />(Qfy) <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 />- <br />Shower, Tub, or Combo <br />Commercial Sink (3-compartment, prep, floor) <br />Clothes Washer <br />IResidential Sink (kitchen, bath, bar) <br />I <br />Dishwasher <br />JUtllity Sink (laundry, mop) <br />Drinking Fountain <br />2 <br />Toilet <br />Floor Drain <br />Urinal <br />Hose Bibb <br />Waste/Water Pipe Repair <br />Ice Maker <br />Water Service Line (Behind meter, private side) <br />Grease Interceptor <br />Water Valves/Fixtures <br />Sand/Oil Interceptor <br />Water Heater - Electric <br />Medical Gas <br />lWaterHeater- Gas <br />Roof Drains <br />10ther <br />(List Type): <br />Sewage Ejector Pump/Sump Pump <br />10ther <br />(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 1 comply with the State Contra^rs Law 1&27 RCW and 296.200A WAC. <br />y <br />Owner/Authorized Agent Signature Date <br />City of Everett Official Use Only <br />PERMIT # <br />(Revised 21812021) <br />