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mom <br /> PLLBING PERMIT APPLICATIIJ <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 /> WASHINGITON CONTACT INFORMATION: (P)425-257-8810 I(E)PermitServices@everettwa.gov I (W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET I Fe'Z \/VA LI-u-� S'r1p =T PARCEL#` A: -I' C I j7 ' 0043 [�314 0-4G) <br /> CITY i�v -�'� STATE y AL ZIP -I ` 201 <br /> SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION: <br /> TENANT/BUSINESS NAME(if non-residential): t/(/tvl 'tea►?-6,utiris� y�S c 5 rz. <br /> CONTACT INFORMATION <br /> OWNER NAME: -t22 W V- vtr 5T Ltr� - WA <br /> OWNER MAILING ADDRESS: STREET ��G` �} Z S►ROAiOWA ' 2- " <br /> CITY 4/'��� Qt`4 A STATE WA. ZIP - , 4D+2_ <br /> OWNER PHONE: L 4 ) 971 - (cA a4 OWNER EMAIL: Gt(Oe-co.4,h•cnli Vl r <br /> CONTRACTOR COMPANY NAME: O W til>✓Y�`t3 N t L iv rzYL 64;2 IJ`�1s7}n.S'21 V- yA-t,r os, <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): N A- CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): N A- <br /> CONTRACTOR ADDRESS: STREET 3 jJQ �'} �F P LJ -t v.1 <br /> CITY '1b- `N✓vim STATE WA- ZIP Ct 3c,7J <br /> CONTRACTOR PHONE: L 4/A5)`3 71- - 'I 7-4 CONTRACTOR EMAIL: c r► e.-1�c�G!c I. <br /> PRIMARY CONTACT: .KOWNER ❑ CONTRACTOR 1OTHER(Please Specify) 121y=1 <br /> CONTACT NAME: Cc?N SfA'f.f:w V CONTACT PHONE: (4 ) '}- - (v ct Zc(��D� L/O 2 //`S— <br /> �� 3 ct 2 ul CONTACT EMAIL: car- <br /> / / <br /> PLUMBING PERMIT INFORMATION <br /> VALUATION OF WORK:$ 2S `= ASSOCIATED PERMIT#(if applicable): <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 /> G6 Uvt��1't�- K c p co K-1�' C.tf 'G3a 1 vta,....1 '-t ,4 ` \A F' i <br /> PLUMBING PERMIT FIXTURE COUNT(SCOPE OF WORK) <br /> Fixture Fixture <br /> Count List of Fixtures <br /> Count List of Fixtures <br /> (Qty) (Qty) <br /> Backflow Prevention Device(Inside Building)-select devices below: Z 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 /> I 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.lam 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 /> 1/ PERMIT# <br /> 7 L� n7 — 0Zq <br /> /i Z-� 2� 2 Cti <br /> Owner/Authorized Agen Signature Date (Revised 4/21/2022) <br />