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PLUMBING PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> EVERETT SUBMITTAL INSTRUCTIONS:Drop off hard copy completed paper application to 3200 Cedar Street 2nd Floor Intake Drop Box. <br /> WAIIHINOTON CONTACT INFORMATION:(P)425-257-8810 1(E)PermitServices@everettwa.gov I(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET bLf /! V v� PARCEL#: (� <br /> j," _,.�� CrTV 9rATE A/ L1_ ZIP Z® <br /> SUITE/UNIT#: FLOOR#: ADDITION/AL LOCATION INFORMATION: <br /> TENANT/BUSINESS NAME(if non-residential): S0 vty- s r t 5 ��• C i ,-� <br /> CONTACT INFORMATION <br /> OWNER NAME: t_ >� <br /> OWNER MAILING ADDRESS: STREET ( 12 Z f <br /> t k cm STATE t, ZIP ?� <br /> OWNER PHONE: -Z OL - -7 J - &-11-7 ^OWNER EMAIL: J Ur <br /> CONTRACTOR COMPANY NAME: <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): <br /> CONTRACTOR ADDRESS: STREET <br /> crry STATE ZIP <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> PRIMARY CONTACT: ( OWNER ❑CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: <br /> Lk 1, CONTACT EMAIL: J •I yam, L � J Y n' <br /> PLUMBING PERMIT INFORMATION <br /> VALUATION OF WORK:$ 4�� ASSOCIATED PERMIT#(if applicable): <br /> IValualion shall Include the prevailing fair market value of all labor,materials,and equipment needed to complete the work,whether actuauy paid or not) <br /> BUILDING TYPE: ❑SFR ❑Townhouse ❑Duplex ❑ADU ❑Multi-Family-#Units: fACommercial EAccessory Structure <br /> DESCRIPTION OF WORK: ` � <br /> �jtJvfJ frt) Z ! �✓,vt7 �c . ti .vyl tr*.cnk wm>� S- , k <br /> PLUMBING PERMIT FIXTURE COUNT(SCOPE OF WORK) <br /> Fixture Fixture <br /> Count List of Fixtures Count List ofFixtures <br /> (Qty) (Qty) <br /> Backflow Prevention Device(Inside Building)-select devices below: 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 Unnal <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 lWater Heater-Electric <br /> Medical Gas Water Heater-Gas <br /> Roof Drains Other(List Type): <br /> Sewage Ejector Pump/Sump Pump 10ther(List Type): <br /> ACKNOWLEDGEMENT I have reviewed this application and confirm the information contained herein is true and correct.Work dole 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# <br /> apL.3 <br /> Owner/ oriz Agent Signature Date (Revised 4/21/2022) <br />