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PleMBING PERMIT APPLICAAN <br /> EVERETT 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 /> 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 4920 24TH AVE W. PARCEL#: 00567900400402 <br /> aTY EVERETT STATE WA ZIP 98203 <br /> SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION: <br /> TENANT/BUSINESS NAME(if non-residential):N/A <br /> CONTACT INFORMATION <br /> OWNER NAME:4900 24TH AVE W, LLC <br /> OWNER MAILING ADDRESS: STREET526 N WEST AVE #147 <br /> cITY ARLINGTON STATE WA ZIP 98223 <br /> OWNER PHONE:360-631-5922 OWNER EMAIL:OFFICEMANAGER@FULLWILERCONSTRUCTION.COM <br /> CONTRACTOR COMPANY NAME:FULLWILER CONSTRUCTION INC. <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED):FULLWCI9O3M2 CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): <br /> CONTRACTOR ADDRESS: STREET526 N. WEST AVE. #147 <br /> cITY ARLINGTON STATE WA ZIP 98223 <br /> CONTRACTOR PHONE:360-631-5922 X 3 CONTRACTOR EMAIL:OFFICEMANAGER@FULLWILERCONSTRUCTION.COM <br /> PRIMARY CONTACT: ❑✓ OWNER ❑CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE:360-631-5922 X 3 OR 425-344-7803 <br /> JERKY FtWILER OR MALLORIE HEFLEY CONTACT EMAIL:OFFICEMANAGER@FULLWILERCONSTRUCTION.COM <br /> / 7 PLUMBING PERMIT INFORMATION <br /> VALUATION OF WORK:$15,000 . ASSOCIATED PERMIT#(if applicable):TBD <br /> (Valuation shall include the prevailing fair market value of all labor,materials,and equipment needed to complete the work,whether actually paid or not.) <br /> BUILDING TYPE: RJSFR ❑Townhouse ❑Duplex ❑ADU ❑Multi-Family-#Units: ❑Commercial ❑Accessory Structure <br /> DESCRIPTION OF WO Kam: ew construction of 2-story SFR, site is currently vacant land <br /> PLUMBING PERMIT FIXTURE COUNT (SCOPE OF WORK) <br /> Fixture Fixture <br /> Count List of Fixtures Count List of Fixtures <br /> (Qty) (Qty) <br /> Backflow Prevention Device(Inside Building)-select devices below: 4 Shower,Tub,or Combo <br /> Fire Service: ❑DCDA, Domestic Service:❑RPBA❑DCVA o Commercial Sink(3-compartment,prep,floor) <br /> Clothes Washer 6 Residential Sink(kitchen,bath,bar) <br /> f Dishwasher i Utility Sink(laundry,mop) <br /> o Drinking Fountain 3 Toilet <br /> o Floor Drain 0 Urinal <br /> 3 Hose Bibb o Waste/Water Pipe Repair <br /> Ice Maker4. SerDtoe..Ltne-f$ehind meter,private side) <br /> o Grease Interceptor o Water Valves/Fixtures <br /> o Sand/Oil Interceptor i Water Heater-Electric <br /> o Medical Gas o Water Heater-Gas <br /> o Roof Drains Other(List Type): <br /> o 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 /> T# <br /> _ � <br /> L!� 7512.10L7� II 2c2,l — 0 2_, <br /> Owner/Authorized Agent Signature Date (Revised 2/8/2021) <br />