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PLUMBING PERMIT APPLICATION <br />EVERETT <br />WASHINGTON <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) PermitServices@everettwa.gov I (W) everettwa.gov/permits <br />(Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br />PROJECT SITE ADDRESS: STREET ZQ <br />r(Ve GV PARCEL#: <br />CITY e, <br />�C7 <br />STATE ZIP <br />SUITE/UNIT M FLOOR M <br />ADDITIONAL LOCATION INFORMATION: <br />TENANT/BUSINESS NAME (if non-residential): <br />CONTACT INFORMATION <br />OWNER NAME: r�lll <br />OWNER MAILING ADDRESS: STREET <br />CITY <br />STATE ZIP <br />OWNER PHONE: <br />OWNER EMAIL: <br />CONTRACTOR COMPANY NAME: Al It <br />C , <br />WA STATE CONTRACTOR LICENSE #(REQUIRED): <br />CITY OF EVERETT BUSINESS LICENSE #(REQUIRED): JL <br />CONTRACTOR ADDRESS: STREET 2 Z <br />A <br />CITY <br />STATE ZIP D � Z <br />CONTRACTOR PHONE: () mac_ Q <br />CONTRACTOR EMAIL: Alt j(jjaa,2j <br />0 1 G L <br />PRIMARY CONTACT: ❑ OWNER JACONTRACTOR ❑ OTHER (Please Specify) <br />CONTACT NAME: tit � � <br />A5 �, <br />CONTACT PHONE: <br />CONTACT EMAIL: Alt ouaiukIU kALLIZfpQ ��1 G r <br />PLUMBING PERMIT INFORMATION <br />VALUATION OF WORK: $ j(xj <br />1� <br />ASSOCIATED PERMIT # (if applicable): .3 •23b 2 " d cl <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 <br />❑ADU []Multi -Family - # Units: ❑Commercial ❑Accessary Structure <br />DESCRIPTION OF WORK: s <br />r���af <br />c <br />IV U S �LOLC/ey , <br />PLUMBING PERMIT FIXTURE <br />COUNT (SCOPE OF WORK) <br />Fixture <br />Count <br />(Qty) <br />List of Fixtures <br />Fixture <br />Count <br />MIA <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 focal late. 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 />s <br />Signature <br />City of Everett Official Use Only <br />PERMIT # <br />(Revised 412112022) <br />ti <br />