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3 <br /> 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 I(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET La (oo St s tos\ PARCEL#: Z8041 O 3 e l'f Co <br /> CITY Q or(__ STATE (..A.). ZIP 98014 <br /> SUITE/UNIT#: FLOOR#:-• j/ S 'F r I ADDITIONAL LOCATION INFORMATION: <br /> TENANT/BUSINESS NAME(if non-residential): <br /> CONTACT INFORMATION <br /> OWNER NAME: ?;l b�„-J Cu �Atv� va.Sty wc�h�✓� <br /> OWNER MAILING ADDRESS: STREET ?U '&.jy,- I Z9 3 <br /> CITY 1�\(JLV.1jV 1(L STATE �..,j (ZIP 9C67,, <br /> OWNER PHONE: ('I ZS IF 1,SS( II OWNER EMAIL: �; tart( Ctrs(u ivt Co;�Sv u� ti t1 Cif W��' •cot-4 <br /> CONTRACTOR COMPANY NAME: al.S-\-aN C� �t,cv� C00.sLr <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED):,605.- r 91.E Ty(, CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): `5~3 3 f, <br /> CONTRACTOR ADDRESS: STREET 0 lit x (Zt( <br /> CITY 10k0-,r LJ SO l Ue STATE V.J i"-- ZIP �fe3 2.7 D <br /> CONTRACTOR PHONE: '. c co f. b S.)t CONTRACTOR EMAIL: 3L,L50.41-S C h,Mtn(.164/4:\-vr„i-ci ute, ,,M4 t i <br /> PRIMARY CONTACT: [ OWNER ❑CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: <br /> ? (( CONTACT PHONE:CONTACT EMAIL: awl,wl,GA.S r'Y‘ t-.C`�0.`A_,r A G`i'Y�t:.t1. Ak7fv1'1 <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: QSFR ❑Townhouse ❑Duplex ❑ADU ❑Multi-Family-#Units: ❑Commercial ❑Accessory Structure <br /> DESCRIPTION OF WORK: �{ I / <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)r y-s(elect devices below: Shower,Tub,or Combo <br /> IL` <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 3 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 /5 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 /> /2r ` U PERMIT# r7 l 7 _('II <br /> -67- <br /> caner/Authorize ent Sig Lure Date / (Revised 2/8/2021) <br />