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• <br /> E P UMBING PERMIT APPLICIION <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)everetteps@everettwa.gov I(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET 200÷- ajar 1„1.-,eQ.4 PARCEL#:VVI 5 L 3 /Q I 000 ioo <br /> CITY STATE 1A1 ZIP V31.0 , <br /> SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION: <br /> TENANT/BUSINESS NAME(if non-residential): <br /> CONTACT INFORMATION <br /> OWNER NAME: fl OMe Ql rov" <br /> OWNER MAILING ADDRESS: STREET 0-(pc-1/iVt <br /> CITY STATE W' 1 ZIP la2O <br /> OWNER PHONE: 1-1 ) 261-`7 cu,3 OWNER EMAIL: fMtyl e c -i(Jk@ ct; f-co <br /> CONTRACTOR COMPANY NAME: Go r4j`,s coo 4y-1,(4,-L1014_, <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED):CC (Mai t cCP CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): 007563 <br /> CONTRACTOR ADDRESS: STREET g it 1-/ rd A v& vie_ <br /> CITY La ° J€4 'S STATE ZIP qV 2 <br /> CONTRACTOR PHONE: Lj 21) 2 r' ZPI1 1 CONTRACTOR EMAIL: C�V rt QpcjJrtis_sc 1vt 7�.tl 7oivt , <br /> PRIMARY CONTACT: rAIDTHER ciaCoiWNER :,ONTRACTOR (Please Specify) OGl)l�X 5 <br /> CONTACT NAME: CONTACT PHONE: (1.-12.6) 280.- Gj J <br /> aGorei-:/ieptri CONTACT EMAIL: n ;Q -;c1. aivicti I-CQtA, <br /> �,,.,,,�/+.�� PLUMBING PERMIT INFORMATION <br /> VALUATION OF WORK: $ /2,000 ASSOCIATED PERMIT#(if applicable): <br /> (Valuation shall include the prevailin fair market value of all labor,materials,and equipment needed to complete the work,whether actually paid or not.) <br /> BUILDING TYPE: FR ownhouse duplex �DU ��ulti-Family-#Units: :ommercial [ ccessory Structure <br /> DESCRIPTION O- RK: <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 Pr n Device(Inside Building3—select s below: Shower,Tub,or Combo <br /> Fire Service CDA, Domestic Service IPB/ CVA Commercial Sink(3-compartment,prep,floor) <br /> Clothes Was er Residential Sink(kitchen,bath,bar) <br /> 1 Dishwasher Utility Sink(laundry,mop) <br /> Drinking Fountain .5 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 /> PERMIT# U G k k <br /> 0 ne uthorl ed t ' u e Date (Revised 2/8/2021) <br />