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PJMBING PERMIT APPLICAN <br /> EVE R E T T 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)PermitServices@everettwa.gov I(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION J,// �,,rl <br /> PROJECT SITE ADDRESS: STREET�3' rO,S Rovkt✓' AVE PARCEL <br /> '#_:/ (/ / 3'�ti' t"t'�7 <br /> CITY F1/ti'e 't STATE �✓✓` - ZIP <br /> SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION: <br /> TENANT/BUSINESS NAME(if non-residential): <br /> j I CONTACT INFORMATION <br /> OWNER NAME: RQD 0 y f n/fry o /J <br /> OWNER MAILING ADDRESS: STREETam/3 YDI G,�7d( /T(- S L�= /1 G r <br /> CITY Re' ft STATE i't4- ZIP /Q 07 7 <br /> OWNER PHONE:y225-Z2(- r( OWNER EMAIL: R fon kvvt frgorinse Ivo!(ow, <br /> CONTRACTOR COMPANY NAME: ,ig:\C it5CiV1 600 rrrTdir)3 <br /> WA STATE CONTRACTOR LICENSE#(REQUIREDikrt9" ' /7/700Y OF EV)•f"1' TT BUSINESS LICENSE#(REQUIRED): Freeepite730 <br /> CONTRACTOR ADDRESS: STREET ,2672"'[ 5e- '-1g2r"'l.�'T' <br /> CITY vnricACt4.4) r��STATE�,/F ZIP gsozo. <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> PRIMARY CONTACT: ❑OWNER r CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: 310-23V- 23ao <br /> `y/ s ew CONTACT EMAIL: kisooderf co"�'1/'a64,04 C y(.i,4Df!•Gae+'t <br /> PLUMBING PERMIT INFORMATION <br /> VALUATION OF WORK:$ Z/8Dd 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: n lO k, h t� n' 1/ ecFerce4' wu!/ ket 1T pered- <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 Prevention Device(Inside Building)-select devices below: Shower,Tub,or Combo <br /> Fire Service: ❑DCDA, Domestic Service:ERPBA❑DCVA ( 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 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 . 7 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> �"�7`�Z Z PERMIT# <br /> 2 ZOCO 031 <br /> Ow er/Authonzed Agent Signature Date (Revised 4/21/2022) <br />