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WI Imo <br /> PL!BING PERMIT APPLICATION <br /> EVERETT SUBMITTAL CITY OF EVERETT PERMIT SERVICES <br /> 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 SITE ADDRESS: STREET 10318 Evergreen Way PARCEL#: 00535200001001 <br /> ciTY Everett S1Att_ WA ZIP 98204 <br /> SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION: <br /> TENANT/BUSINESS 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 OWNER EMAIL:TAYLORH@WOODSCOFFEE.COM <br /> CONTRACTOR COMPANY NAME:CONTRACT HAS NOT BEEN AWARDED <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): Q " [CITY <br /> OF EVERETT BUSINESS LICENSE#(REQUIRED): <br /> /l�i <br /> CONTRACTOR ADDRESS: STREET Cw 1 1UI V� 7 l� <br /> CITY STATE ZIP <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> PRIMARY CONTACT: I]OWNER [Ti CONTRACTOR El OTHER(Please Specify) <br /> CONTACT NAME: _ CONTACT PHONE:360.393.7553 <br /> 1 AYLOR HERMAN 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 ❑ADJ ❑Multi-Family-#Units: ❑✓Commercial ❑Accessory Structure <br /> DESCRIPTION OF WORK: UNDERGROUND ROUGHT WASTE LINE AND WATER SUPPLY, ROUGH WALL WATER <br /> SUPLY, FIXTURE AND TRIM, VENTING PENETRATIONS PER ENGINEERED PLAN. <br /> PLUMBING PERMIT FIXTURE COUNT (SCOPE OF WORK) <br /> Fixture Fixture <br /> Count List of Fixtures Count List of Fixtures <br /> (Qty) (Qty) <br /> 4 Backflow Prevention Device(Inside Building)-select devices below: Shower,Tub,or Combo <br /> Fire Service:❑DCDA, Domestic Service:❑✓RPBA❑DCVA 1 Commercial Sink(3-compartment,prep,floor) <br /> Clothes Washer Residential Sink(kitchen,bath,bar) <br /> Dishwasher Utility Sink(laundry,mop) <br /> Drinking Fountain 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 j.."----Virdte(H—e'aterElectric VA. 1 Y e / uri <br /> Medical Gas Water Heater-Gas �wwvvv��` 'V" <br /> Roof Drains Other(List Type): FLOOR SINK <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 <br /> j 3 2 I 2l \ \-- 00E <br /> Owner/A horized Agent Signature Date (Revised 2/8/2021) <br /> 1 <br />