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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 I(1-)PermitServices@everettwa.gov I(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET PARCEI,#: (' r7(� yD062 <br /> WG CIN �v+e y��- L STATE ZIP02 <br /> SUITEIUN(T#: FLOOR#: ADDITIONAL LOCATION INFORMATION: <br /> TENANTIBUSINESS NAME(if non-residential): 00M ZLe= <br /> L CONTACT INFORMATION <br /> OWNER NAME: <br /> OWNER MAILING ADDRESS: STREET <br /> CITY � e � [ STATE � ZIP <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR COMPANY NAME: <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): f,( ITY OF EVERETT BUSINESS LICENSE#(REQUIRED): S& D <br /> CONTRACTOR ADDRESS: STREET ,U, 4,`! <br /> cnY Q , ,V STATE ZIP <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> PRIMARY CONTACT: WNER ONTRACTOR L THER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: <br /> Fa LZ CONTACT EMAIL: <br /> PLUMBING PERMIT INFORMATION <br /> VALUATION OF WORK:$ S4 �(� 0� ASSOCIATED PERMIT#(if applicable): 3 cit L( --ip L <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: FR ownhouse I u lex DU tilt€-Family-#Units: ommereial ccessory Structure <br /> DESCRIPTION O / RK: <br /> Plu v4gtl- 2- <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 Pr n Device(Inside Buildin Vec, below: Shower,Tub,or Combo <br /> Fire Service CDA, Domestic Servic PB CVA Commercial Sink(3-compartment,prep,floor) <br /> Clothes Was _er 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/O)i Interceptor Water Heater-Electric <br /> meuicai i�as 'VJeiel Heaiel-Baas <br /> Roof Drains lbther(List Type): <br /> Sewage Ejector Pump/Sump Pump 10ther(List Type): <br /> ACKNOWLEDGEMENT:l 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 lave 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 ovmar of this property to perforin the work for which application is made, <br /> and f comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> 1 ` PERMIT# <br /> 17 <br /> Owner/Authorized Agent Signature p Date (Revrrsed 412V2022) <br />