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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) everetteps@everettwa.gov I (W) everettwa.gov/permits <br />(Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br />PROJECT SITE ADDRESS: STREET 10318 Evergreen way PARCEL #: 00535200001001 <br />CITY Everett STATE WA ZIP 98204 <br />,SUITE/UNIT #: FLOOR #: ADDITIONAL LOCATION INFORMATION: <br />TENANTIBUSINESS NAME (if non-residential): WOODS COFFEE <br />CONTACT INFORMATION <br />OWNER NAME: TAYLOR HERMAN - WOODS COFFEE <br />OWNER MAILING ADDRESS: STREET 191 18TH ST <br />CITY LYNDEN STATE WA ZIP 98264 <br />OWNER PHONE: 360.393.7553 <br />OWNER EMAIL: TAYLORH@WOODSCOFFEE.COM <br />CONTRACTOR COMPANY NAME: CONTRACT HAS NOT BEEN AWARDED <br />WA STATE CONTRACTOR LICENSE #(REQUIRED): <br />CITY OF EVERETT BUSINESS LICENSE #(REQUIRED): <br />CONTRACTOR ADDRESS: STREET <br />CITY STATE ZIP <br />CONTRACTOR PHONE: <br />CONTRACTOR EMAIL: <br />PRIMARY CONTACT: ❑✓ OWNER ❑ CONTRACTOR ❑ OTHER (Please Specify) <br />CONTACT NAME: <br />TAYLOR HERMAN <br />CONTACT PHONE: 360.393.7553 <br />CONTACT EMAIL:TAYLORH@WOODSCOFFEE.COM <br />PLUMBING PERMIT INFORMATION <br />VALUATION OF WORK: $15,000 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: UNDERGROUND BOUGHT WASTE LINE AND WATER SUPPLY, ROUGH WALL WATER <br />SUPLY, FIXTURE AND TRIM, VENTING PENETRATIONS PER ENGINEERED PLAN. <br />PLUMBING PERMIT FIXTURE <br />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 />4 <br />Backflow Prevention Device (Inside Building) -select devices below: <br />Fire Service: ❑DCDA, Domestic Service: ❑✓ RPBA ❑DCVA <br />Shower, Tub, or Combo <br />Commercial Sink (3-compartment, prep, floor) <br />Clothes Washer <br />+ <br />Residential Sink (kitchen, bath, bar) <br />Dishwasher <br />Utility Sink (laundry, mop) <br />Drinking Fountain <br />Toilet <br />Y <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 />Water Heater - Gas <br />Roof Drains <br />4 <br />Other i List Type): FLOOR SINK <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 be authorized in writing from the <br />Building Official beforeAling 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 Rate Contractors Law 18.27 RCW and 296.200A WAC. <br />/// t /I- I <br />Agent Signature Date <br />City of Everett Official Use Only <br />PERMIT # <br />(Revised 21812021) <br />