1019 100TH ST SW 2024-08-06 - Laserfiche WebLink

PLUMBING PERMIT APPLICATION EVERETT SUBMITTAL CITY OF EVERETT PERMIT SERVICES INSTRUCTIONS:Drop off hard copy completed paper application to 3200 Cedar Street 2nd Floor Intake Drop Box. WASHINGTON CONTACT INFORMATION:(P)425.257.8810 I(E)everetteps@everettwa.gov I(W)everettwa.gov/permits (Blue or Black Ink Only Please) PROJECT SITE INFORMATION PROJECT SITE ADDRESS: STREET /c/7 (a v Ew S t SZ PARCEL#: Z$?1 13v co`(o CITY L I'e-r STATE WPS ZIP 1dji 61 4 SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION: TENANT/BUSINESS NAME(if non-residential): (( CONTACT INFORMATION OWNER NAME: Bt,�i\-c'ora:` Ct Cco•C\Y.."-Aios- OWNER MAILING ADDRESS: STREET V, 3 3en 1 Z y CITY mf s,,,+I i� STATE ZIP IS Z7 OWNER PHONE: c}Z.c ( 5/ OWNER EMAIL: l,tk,s� Co.::Yl.", «\.sTr 'v rt Lj~-4-I I•LvA CONTRACTOR COMPANY NAME: BA L cc. c,.,`5.6,„N, C� ,� r�kC D<t WA STATE CONTRACTOR LICENSE#(REQUIRED): r C(a, CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): 5 53 36 CONTRACTOR ADDRESS: STREET p. a L4 3 CITY AM-VISA/I ( (a- STATE 'of i ZIP ( `Z<.2 1 0 CONTRACTOR PHONE: `-it-S 5S-I .:• 655I CONTRACTOR EMAIL: 13c�i-c-rS C-oa rJrccCO5&wtg( c.oV�l PRIMARY CONTACT: nt OWNER ❑CONTRACTOR ❑OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: c{Z5 to 5CJ P0.�1 �iw��\clr L` CONTACT EMAIL: ,\c` ,S CuS�t; v� �v�isr v-C��L.)t). 1 f •ti lL PLUMBING PERMIT INFORMATION VALUATION OF WORK: $ ASSOCIATED PERMIT#(if applicable): (Valuation shall include the prevailing fair m ._.. , __._...... ,-,iaterials,and equipment needed to complete the work,whether actually paid or not.) BUILDING TYPE: OirSFR ❑Townhouse ❑Duplex ❑ADU ❑Multi-Family-#Units: ❑Commercial ❑Accessory Structure DESCRIPTION OF WORK: �CLL) g_ PLUMBING PERMIT FIXTURE COUNT (SCOPE OF WORK) Fixture Fixture Count List of Fixtures Count List of Fixtures (QtY) (Qty) Backflow Prevention Device(Inside Building)-select devices below: ;2 Shower,Tub,or Combo Fire Service:❑DCDA, Domestic Service:( I,RPBA EDCVA Commercial Sink(3-compartment,prep,floor) / Clothes Washer Residential Sink(kitchen,bath,bar) / Dishwasher Utility Sink(laundry,mop) Drinking Fountain 3 Toilet Floor Drain Urinal Hose Bibb / Waste/Water Pipe Repair Ice Maker / Water Service Line(Behind meter,private side) / Grease Interceptor /5— Water Valves/Fixtures Sand/Oil Interceptor Water Heater-Electric Medical Gas f Water Heater-Gas Roof Drains Other(List Type): Sewage Ejector Pump/Sump Pump Other(List Type): 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 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 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, and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. City of Everett Official Use Only (2. 0 / PERMIT#"_ p Z1Z'V'5 Owner/Authorized Agent Sig ture Date (Revised 2/8/2021)