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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 1(E)everetteps@everettwa.gov I(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET <br /> 10 (OD S.r SIA: PARCEL#: 09(30t) '30 tyov <br /> CITY t/,2_•/e.4J STATE ZIP <br /> SUITE/UNIT#: FLOOR#:),( 3.z Er) <br /> ADDITIONAL LOCATION INFORMATION: <br /> TENANT/BUSINESS NAME(if non-residential): <br /> 11 CONTACT INFORMATION <br /> OWNER NAME: C Ca <br /> OWNER MAILING ADDRESS: STREET ?. c7 -?:›oy ( z_ 3 <br /> CITY a.v. (`S ; ��t? STATE �� ZIP �Zl0 <br /> OWNER PHONE: `-t'1,5 �7 to b5S I OWNER EMAIL: 1?j,x5}e re( Sh; < � �v, C .„,(t9 5r w - Motu <br /> CONTRACTOR COMPANY NAME: 3ty,4 0..,,. C ti� CO I,•Str v.-.S-t <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): L CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): S 33 3 (o <br /> CONTRACTOR ADDRESS: STREET 'Fs p I z 4 <br /> CITY tot of r STATE W ZIP en Z'T 6 <br /> CONTRACTOR PHONE: 77_5 (61 t< (,S-S( CONTRACTOR EMAIL: \3 Cc.isk � o.;��rh �� GJme,:( . Lv« <br /> PRIMARY CONTACT: JWNER ❑CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: <br /> ci w( �L����w ( CONTACT EMAIL: «S1 ct ` j <br /> 1 Ct?���cH�Cc .tiS<r��c9°Ll��uv�c�� i pc` <br /> PLUMBING PERMIT INFORMATION <br /> VALUATION OF WORK:$ 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: ESFR ❑Townhouse ❑Duplex ❑ADU ❑Multi-Family-#Units: ❑Commercial ❑Accessory Structure <br /> DESCRIPTION OF WORK: <br /> C 'kje <br /> PLUMBING PERMIT FIXTURE COUNT (SCOPE OF WORK) <br /> Fixture Fixture <br /> Count List of Fixtures Count List of Fixtures <br /> (Qhr) (QtY) <br /> Backflow Prevention Device(Inside Building)-select devices below: -3 Shower,Tub,or Combo <br /> Fire Service:❑DCDA, Domestic Service:ERPBA❑DCVA Commercial Sink(3-compartment,prep,floor) <br /> Clothes Washer j— Residential Sink(kitchen,bath,bar) <br /> / Dishwasher Utility Sink(laundry,mop) <br /> Drinking Fountain •3 Toilet <br /> Floor Drain Urinal <br /> Z Hose Bibb / Waste/Water Pipe Repair <br /> / Ice Maker / Water Service Line(Behind meter,private side) <br /> Grease Interceptor /6 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 comp) with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> •�� PERMIT# p <br /> A. -74202_,/ <br /> Owner/Authorized Agent Si gnat•re Date (Revised 2/8/2021 <br /> 9 9 ) <br />