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M 0 • <br /> `i PLUMBING PERMIT APPLICATION <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 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 / 2 I;t/ C 495 FAO o+ PARCEL#: <br /> CITY eveiw7 STATE t,09' ZIP ',1 w e, <br /> SUITE/UNIT#: FLOOR#: A,,,,s2,ka, <br /> ADDITION L LOCATION INFORMATION: <br /> TENANT/BUSINESS NAME(if non-residential): I 1 W <br /> CONTACT INFORMATION <br /> OWNER NAME: Po;A 16 <br /> OWNER MAILING ADDRESS: STREET f 2- I„Je /- 2c5(4 <br /> CITY C_vET CTj]`— STATE If'A— ZIP ggeis• <br /> OWNER PHONE: b 0 9- r/'(� 9-.??43 OWNER EMAIL: 0 d/1k4- r n) 947 00__L 0ill cQ f er <br /> CONTRACTOR COMPANY NAME: Doc rS �Xc ve.h o at jr . E'7vie_e-5 CC C <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): r)0 C SEES 85s-p6ICITY OF EVERETT BUSINESS LICENSE#(REQUIRED):(o-vUtC.I <br /> CONTRACTOR ADDRESS: STREET Z �2 / 3 7-#1 S / S 1+1 J <br /> CITY l:—v STATE (A ZIP g 6)I <br /> CONTRACTOR PHONE: Sag- ‘ 70 EMAIL:..... D0 c S EKC 0- - _ .. .. Q L� co/'`^2�� S CONTRACTOR E ✓� --/-.), <br /> PRIMARY CONTACT: OWNER ❑CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: (e.YQti /-4 4‘) CONTACT PHONE: _c0c^ t 70 -- 2‘ , <br /> CONTACT EMAIL: <br /> PLUMBING PERMIT INFORMATION <br /> VALUATION OF WORK:$ S0 0 ASSOCIATED PERMIT#(if applicable): <br /> (Valuation shall include the prevailing hair market value of all labor,materials,and equipment needed to complete the work,whether actually paid or not.) <br /> BUILDING TYPE: ❑SFR ❑Townhouse ❑Duplex ❑ADU__ vlulti-Family-#Units: ❑Commercial ❑Accessory Structure <br /> DESCRIPTION OF WORK: ��4 r2 l 1'71 4� L7G 1-`if'' <br /> PLUMBING PERMIT FIXTURE COUNT (SCOPE OF WORK) <br /> Fixture Fixture <br /> Count List of Fixtures Count List of Fixtures <br /> (Q430 (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 t 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 /> --- PE <br /> 22_05 -0� <br /> /Authorized Agent Signature Date (Revised 2/8/2021) <br />