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1 i <br />EVERETT <br />WASHINGTON <br />PLUMBING PERMIT APPLICATION <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) PermilServices@everettwa.gov I (W) everettwa.gov/permits <br />(Blue or Black Ink Only Please) PROJECT S/ IT�E INFORMATION <br />PROJECT SITE ADDRESS: -;`VI STREET v (/� PARCEL #: (d � C� �•� O OOOO 30� <br />CITY O eIV� I STATE U3'pD \ ZIP <br />SUITEWNIT #: FLOOR #: ADDITIONAL LOCATION INFORMATION: <br />TENANT/BUSINESS NAME (if non-residential): <br />CONTACT INFORMATION <br />OWNER NAME: yL(� �S'% C I�UJ : / C //V VV <br />\\ <br />OWNER MAILING ADDRESS: STREET L-> <br />CITY C - 2 L51 / STATE ZIP 1<2 <br />OWNER PHONE: - \ l ��� <br />OWNER EMAIL: Ut-1 e HAC <br />CONTRACTOR COMPANY NAME: li V," VLIA1_ <br />WA STATE CONTRACTOR LICENSE #(REQUIRED): <br />CITY OF EVERETT BUSINESS LICENSE #(REQUIRED): <br />CONTRACTOR ADDRESS: STREET <br />CITY STATE ZIP <br />CONTRACTOR PHONE: <br />CONTRACTOR EMAIL: <br />PRIMARY CONTACT: OWNER ❑ CONTRACTOR ❑ OTHER (Please Specify) <br />CONTACT NAME: 5 V�� M 1 �iJ/J <br />CONTACT PHONE: ?�?� <br />CONTACT EMAIL: <br />PLUMBING PERMIT INFORMATION <br />VALUATION OF WORK: $ C� 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: WSFR ❑Townhouse ❑Duplex ❑ADU ❑Multi -Family - # Units: ❑Commercial ❑Accessory Structure <br />DESCRIPTION OF WORK: <br />PLUMBING PERMIT FIXTURE <br />COUNT (SCOPE OF WORK) <br />Fixture <br />Count <br />(Q(Y) <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 />Shower, Tub, or Combo <br />Commercial Sink (3-compartment, prep, floor) <br />Clothes Washer <br />Residential Sink (kitchen, bath, bar) <br />Dishwasher <br />Utility Sink (laundry, mop) <br />Drinking Fountain <br />Toilet <br />Floor Drain <br />Urinal <br />Hose Bibb <br />Waste/Water Pipe Repair <br />Ice Maker <br />Water Service Line (Behind meter, private side) <br />Grease Interceptor <br />Water Valves/Fixtures <br />Sand/Oil Interceptor <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. 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 Con @tors Law 18.27 RCW and 296.200A WAC. <br />` City of Everett Official Use Only <br />- - _ PERMIT # p (, <br />i-u-z3 1 Z� <br />I Signature Date (Revised 412112022) <br />