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sca.,� <br /> PLUMBING PERMIT APPLICATION d (�� <br /> CITY OF EVERETT PERMIT SERVICES <br /> EVERETT 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 (E)everetteps@everettwa.gov I(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET 2 Z GQ (,13 Y A,,- PARCEL#: <br /> CITY V ILk�-' { STATE W A ZIP <br /> SUITE/UNIT M FLOOR#: ADDITIONAL LOCATION INFORMATION: <br /> TENANT/BUSINESS NAME(if non-residential): <br /> CONTACT INFORMATION <br /> OWNER NAME: `_iASov �- %4(ZN041-A �G� ►JN1C�A <br /> OWNER MAILING ADDRESS: STREET (Q 2- GO A"'JC !!'' <br /> CITY 1 G�c p 1 ,— STATE WJ Pr ZIP Z7 2Q <br /> OWNER PHONE: 42s' 4-T- 2-8,2_2r OWNER EMAIL: � a.$C,A S S 4C C kC30 .C-0 M- <br /> CONTRACTOR COMPANY NAME: A POL A o t�WM A 1"6 INC— . <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): I CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): <br /> CONTRACTOR ADDRESS: STREET S46-7 —7 I A-yr N E <br /> cITY 0LAA-A-",r5 is 1 L(.jZ STATE W A- 2?U <br /> CONTRACTOR PHONE: 4z� -- 3$7' 1!5-6-7 CONTRACTOR EMAIL: <br /> PRIMARY CONTACT: FKWNER ❑CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: LLS-, 341 - 2¢,2$ <br /> S opz W-0#,j'J&AY CONTACT EMAIL: a Sb t1 <br /> SS q,k 00. <br /> PLUMBING PERMIT INFORMATION <br /> VALUATION OF WORK:$ go ASSOCIATED PERMIT#(if applicable): <br /> (Valuation shall include the prevaaing fair market value of all labor,materials,and equipment needed to complete the work,whether actually paid or not.) <br /> BUILDING TYPE: ❑�FR ❑Townhouse ❑Duplex ❑ADU ❑Multi-Family-#Units: • ❑Commercial ❑Accessory Structure <br /> DESCRIPTION OF WORK: [ZWpvO-e IW C Aril (VL40A 1 UA 6&4 - �iC+3S�� LnNMSGr Ta j�/tr'M Foote► ✓ts�+r- <br /> ci' <br /> PLUMBING PERMIT FIXTURE COUNT (SCOPE OF WORK) <br /> Fixture Fixture <br /> Count List of Fixtures Count List of Fixtures <br /> (Qw) (Qty) <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) <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: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 /> PERMIT# —� <br /> - — ��. <br /> Owner Authorized Agent Signature Date (Revised 2/8/2021) <br />