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PL�BING PERMIT APPLICATIA <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 ( (W) everettwa.gov/permits <br />(Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br />PROJECT SITE ADDRESS: STREET 3xxx Kromer ST �'�2 �L1(� PARCEL #: 00583978301402 <br />CITY Everett STATE WA ZIP 98201 <br />SUITE/UNIT #: FLOOR #: ADDITIONAL LOCATION INFORMATION: <br />TENANT/BUSINESS NAME (if non-residential): <br />CONTACT INFORMATION <br />OWNER NAME: Dick Kikuchi <br />OWNER MAILING ADDRESS: STREET815 34th ST <br />CITY Everett STATE WA zip 98201 <br />OWNER PHONE: <br />OWNER EMAIL: <br />CONTRACTOR COMPANY NAME: Haack Brothers Homes <br />WA STATE CONTRACTOR LICENSE #(REQUIRED): HaackBI012DZ <br />CITY OF EVERETT BUSINESS LICENSE #(REQUIRED): 053967 <br />CONTRACTOR ADDRESS: STREET3922 87th AVE NE <br />c;,, Marysville STATE WA zip 98270 <br />CONTRACTOR PHONE: <br />CONTRACTOR EMAIL: <br />PRIMARY CONTACT: ❑ OWNER ❑✓ CONTRACTOR ❑ OTHER (Please Specify) <br />CONTACT NAME: <br />Joel Haack <br />CONTACT PHONE:425-290-2429 <br />CONTACT EMAIL:Joel@haackbrothers.com <br />PLUMBING PERMIT INFORMATION <br />VALUATION OF WORK: $9500 <br />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: Plumb new SFR <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 />Backflow Prevention Device (Inside Building) -select devices below: <br />Fire Service: ❑DCDA, Domestic Service: ❑RPBA ❑DCVA <br />s <br />Shower, Tub, or Combo <br />Commercial Sink (3-compartment, prep, floor) <br />Clothes Washer <br />t <br />Residential Sink (kitchen, bath, bar) <br />Dishwasher <br />i <br />Utility Sink (laundry, mop) <br />Drinking Fountain <br />5 <br />Toilet <br />Floor Drain <br />Urinal <br />2 <br />Hose Bibb <br />Waste/Water Pipe Repair <br />Ice Maker <br />1 <br />Water Service Line (Behind meter, private side) <br />Grease Interceptor <br />10 <br />Water Valves/Fixtures <br />Sand/Oil Interceptor <br />t <br />Water Heater - Electric <br />Medical Gas <br />Water Heater - Gas <br />Roof Drains <br />Other (List Type): <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 before being authorized under any circumstance. 1 am the owner, or 1 am authorized by the owner of this property to perform the work for which application is made, <br />and I comply with the State ContractorALaw 18.27 RCW and 296.200A WAC. <br />City of Everett Official Use Only <br />PERMIT-#)n' <br />(Revised 211812021) v <br />