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I <br /> MIMI <br /> LI. PLUMBING PERMIT APPLICATIN <br /> . <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 1(E)everetteps@everettwa.gov I(W)everettwa.gov/permits <br /> (Blue.or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET�y ' \ C qcy \L ) PARCEL#: <br /> cm" Q V Q__\t, STATE ZIP R.VE 6 3 <br /> SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION: <br /> TENANT/BUSINESS NAME(if non-residential): <br /> CONTACT INFORMATION <br /> OWNER NAMErca((o., C'N2 <br /> OWNER MAILING ADDRESS: STREET (7M\O CAc y <br /> CITY STATE �' s ZIP <br /> OWNER PHONE6414 42 OWNER EMAIL: u���o Al-% OA 3 o. P\. co <br /> CONTRACTOR COMPANY NAME: p'�tSkn 9 LLC _ <br /> WA STATE CONTRACTOR LICENSE (REQUIRED),c c,hoe pLl.ck%P A CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): <br /> CONTRACTOR ADDRESS: STREET 10:2t)%La — s-{(\ --" v �S <br /> CITY V�rIC\ (WI STATE C/,A/ ZIP <br /> CONTRACTOR PHON€CK,)211...C, ` 2 �� CONTRACTOR EMAIL:S el nq 4- <br /> PRIMARY CONTACT: fi OWNER ❑CONTRACTOR ❑OTHER(Please Specify) �J <br /> CONTACT NAME: 3`�. p`nCAe CONTACT PHONE: 42....s <br /> Q{ ZS-) q l— S 3 --`2 CONTACT EMAIL.�UC./\��C1 e►bev 421-l46 rML% ,c`enm <br /> PLUMBING PERMIT INFORMATION <br /> VALUATION OF WORK:$ 4, wt, 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: EISFR ❑Townhouse ❑Duplex ❑ADU ❑Multi-Family-#Units: ❑Commercial ❑Accessory Structure <br /> DESCRIPTION OF WORK: <br /> (Av(v\E cn Goviajer k to., <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) 4 <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:1 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 I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> PERMIT#2� f27-tf Uf (� <br /> 0 orized Agent Signature Date (Revised 2/8/2021) t I a <br />