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E 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 j(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET 5 0 f3 �9 L/ to h PARCEL#: A <br /> V <br /> CITY E 'C f/e, (..it STATE Of/ / ZIP 9g2 03 <br /> SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION: <br /> TENANT/BUSINESS NAME(if non-residential): <br /> CONTACT INFORMATION <br /> OWNER NAME: 73a.„rha,ra_7p e <br /> OWNER MAILING ADDRESS: STREET ,5 0 .3 S / r / /-1 vte. 41 <br /> CITY ' STATE VVA" ZIP { 8 203 <br /> OWNER PHONE: 2 /L gg - s 3/ 3 OWNER EMAIL: J 7Yldesijiie( 04 ej / O?i <br /> CONTRACTOR COMPANY NAME: �roPer7/ 01440.e_tr - g��L-��/e,-/2j CZehrt <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED):pro�/���/ 9//OA/ACITY OF EVERETT BUSINESS/,r LICENSE#(REQUIRED):P/O f �di/424 <br /> CONTRACTOR ADDRESS: sTREE-L/0,3 S/� /i A V - � <br /> CITY r-ve r e cif STATE �A ! . / <br /> ZIP 8203 <br /> CONTRACTOR PHONE: c2'2 / 8 ' '/O 3 CONTRACTOR EMAIL: /e2rjale ' OL/( /oC�j,na6l C'd <br /> PRIMARY CONTACT: OWNER ❑ CONTRACTOR ❑OTHER(Please Specify) .�// <br /> CONTACT NAME: �yy� �rr CONTACT PHONE: � g O�/ L 3I6 1 <br /> /B�/a-bara /72'J?Q ) CONTACT EMAIL: J.���`s qn e( Oi6609ina; ant_ <br /> PLUMBINGPERMIT INFORMATION <br /> VALUATION OF WORK: $ a/ 000 • 00 ASSOCIATED PERMIT#(if applicable): /e,2/O7 -/ '9C <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: ❑SFR ❑Townhouse ❑Duplex ❑ADU ❑Multi-Family-#Units: ❑Commercial ❑Accessory Structure <br /> DESCRIPTION OF WORK: <br /> aalh ve od perm% Wa c issv�°d Z' dve/rec./et <br /> Oe e r2 v s- 1 C h-e teed i/ - ;x/i/e 6oyes /•11 e r r o r pee"e <br /> PLUMBING PERMIT FIXTURE COUNT (SCOPE OF WORK) <br /> Fixture Fixture <br /> Count List of Fixtures Count List of Fixtures <br /> (Qty) (Qty) <br /> Backflow Prevention Device(Inside Building)-select devices below: eg., 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#P2108 _ 007 <br /> Owner/Authorized Agent Signature Dat (Revised 2/8/2021) <br />