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<br /> uni PLUMBING PERMIT APPLICATION
<br /> EVERETT cal'or vtfo 11 I'CttMll s(RVICCs
<br /> 1 SUBMITTAL INSTRUCTIONS:1.": r r:tt h,l+it r+Jrt',,,mi,t>t 1 I,,,i„i„11,1r,tf°'rn to 3200 Ceder Street 2n(1 Floor(rttakaa Drop SOX
<br /> wxs.«„arr,v CONTACT INFORMATION.(t')=t<'1.',t 6810I tl )l't' , t., o„es,l,,rr'Wtiw'I CAW M(W)Ovrurrttwi i)oy/porflitI
<br /> (MU°or Black Ink Only Please) PROJECT SITE INFORMATION
<br /> PROJECT SITE ADDRESS: ,, L='1 iIt
<br /> . Nt,4 _PARCEL# (;J/ t ., ) i(,r -
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<br /> SUITEtUNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION:
<br /> TENANT:BUSINESS NAME of wit rosidanh (t.ti): (•,1 IVA Utrt(.V 10 ( ('
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<br /> CONTACT INFORMATION
<br /> OWNER NAME: . ,' ,i . 1,I r):i
<br /> OWNER MAILING ADDRESS: ,rr,,t-) ( (/ (I\ty c)i rt 0)'(' 1
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<br /> rIn e 111D)"1 SIAtt! \NC4 II' /6-7>
<br /> OWNER PHONE e?l:\ r,t Al 2/71 OWNER EMAIL: Llv 1'.) ( [)e) e V A 0 r�iLAt,�'T1 I . t o iy)
<br /> CONTRACTOR COMPANY NAME: -/i�A t)IU ivt‘rL � ( k''t' f
<br /> WA STATE CONTRACTOR LICENSE#(REUUIRLD):L1 6 CITY OF EVERETT BUSINESS LICENSE e(REOUtRED):
<br /> CONTRACTOR ADDRESS: sterna / Oyu`j 2 /Eh I\`✓e- N i `/ J
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<br /> CONTRACTOR PHONE: (i,Ur,A 2OZ- ?)7_,go CONTRACTOR EMAIL: /k(114it1 ((ItS'N^ pIr.)ivt,6' l� • CUB
<br /> PRIMARY CONTACT: ROWNER 0 CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: CC7Q( I3 22~ l'jr'�r-�
<br /> e t �tO7CO CONTACT EMAIL:t'1o(t\ I°t)( 'tb"tcrot�'Lj:t<t( 1 .( 0 '
<br /> PLUMBING PERMIT INFORMATION
<br /> VALUATION OF WORK:$ ,),(?.)(l . 03 ASSOCIATED PERMIT#(it applicable):
<br /> \aaGtllon Shur inc unio did nrca a6rti)fair ma:WI value of all Iaior,idaldnals.and equ,pmoni nrtded In comoldle did AOuk.whether ACIuffil,,paid ca not 1
<br /> BUILDING TYPE: DSFR ❑Townhouse EDuplex DADU ©Multi-Family-#Units: f Cornmerciai ❑Accessory Structure
<br /> DESCRIPTION OF WORK: C..)lr cAsS4, - a 5"l� Ciitl(0 v 10( 3 cUivtile,r'{ moo- S`;er,>�,
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<br /> CI f -7z S.< t act f) 2 S let(L O I'1 S ;'<.)Y Z, Co yyt d- Writ t S t ilL a vt.tr lei t 'in e ,
<br /> PLUMBING PERMIT FIXTURE COUNT(SCOPE OF WORK)
<br /> Fixture Fixture
<br /> Count List of Fixtures Count List of Fixtures
<br /> (WY) (Oty)
<br /> Backllow Prevention Device(Inside Building),select devices below: Shower.Tub,or Combo
<br /> Fire Service:❑DCDA, Domestic Service:0RPBA EIDCVA ( 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 /> X Floor Drain` Urinal
<br /> Hose Bibb Waste/Water Pipe Repair
<br /> Ice Maker Water Service Lino(Behind meter private side)
<br /> ,t”( Grease Interceptor t1/� Water ValvestFixtures
<br /> Sand/Oil Interceptor Water Heater•Electric
<br /> Medical Gas Water tteater-Gas
<br /> Root Drains Other(List Type).
<br /> Sewage Elector PumptSwnp Pump Other(List'1ype),_._.._,
<br /> ACKNOWLEDGEMENT:I have reviewed this application and confirm the information contained heroin 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 t 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 2?RCW and 296 200A WAC
<br /> City of Everett Official Use Only
<br /> PERMIT# ?2 3 03 J O^
<br /> Owner/Authorized Agent Signature Date (Revised 4/21 2022)
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