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PLUMBING PERMIT APPLICATION <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 1(E)everetteps@everetlwa.gov I(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET 1 C ( ,1�y r e� t W ti PARCEL#: <br /> CITY J tet-•t STATE ZIP <br /> ( SUITEIONIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION: <br /> TENANT/BUSINESS NAME(if non-residential): <br /> '1_121 <br /> � CONTACT INFORMATION <br /> OWNER NAME: t� t' -5 Q k_CL <br /> OWNER MAILING ADDRESS: STREET 2'3 c 2 r Z \\i <br /> CITY STATE W rl— ZIP <br /> OWNER PHONE: ��0 g+1~� O J OWNER EMAIL: V 1--c.h A— C xacr`u <br /> CONTRACTOR COMPANY NAME: .1� K LA b :a-A t k —L)I, ,`y L. LS— <br /> WA <br /> _S—WA STATE CONTRACTOR LICENSE#(REQUIRED):RKH0KKH1!8)KQ1clTY OF EVERETT BUSINESS LIC NSE#(REQUIRED): <br /> CONTRACTOR ADDRESS: STREET <br /> CITY <br /> 2 3 'L -�� 5 l ��_ STATE YL ZIP <br /> CONTRACTOR PHONE: 6 S,_S_ - L(O CONTRACTOR EMAIL: �G I'ct h 2-- <br /> PRIMARY <br /> PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR ❑OTHER(Please Specify) �-- �--L <br /> CONTACT NAME: CONTACT PHONE: <br /> CONTACT EMAIL: <br /> PLUMBING PERMIT INFORMATION 7111 3 U 7— D <br /> VALUATION OF WORK:$ ASSOCIATED PERMIT#(if applicable): <br /> (Valuation shall include the prevailing falx 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: t �� �� �� � cL 5 1,N <br /> PLUMBING PERMIT FIXTURE COUNT (SCOPE OF WORK) <br /> Fixture Fixture <br /> Count List of Fixtures Count List of Fixtures <br /> (Qty) (Qfy) <br /> Backflow Prevention Device(Inside Building)-select devices below: Shower,Tub,or Combo <br /> Fire Service:❑DCDA, Domestic Service:❑RPBA❑DCVA ' Commercial Sink(3-compartment,prep,floor) <br /> Clothes Washer Residential Sink(kitchen,bath,bar) <br /> Dishwasher Utility Sink(laundry,mop) <br /> tT 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): F ' rr' r <br /> Sewage Ejector Pump/Sump Pump Other(List Type): te-•-c a Jr_ <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 1 am authorized by the owner of this property to perform the work for which application is made, <br /> and 1 comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> PERMIT# <br /> 2_0 Z-:5 COV�0(71- - 0 <br /> Ow e'/Authorized A ent S nature Date (Revised 2/8/2021) <br />