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PLUMBING PERMIT APPLICATION <br /> EVERETT SUBMITTAL INSTRUCTIONS: <br /> OF EVERETT PERMIT SERVICES <br /> S: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)PermitServices@everettwa.gov (W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: / PARCEL#: <br /> ff7T <br /> J <br /> 7 �7 CrrY V STATE ZIP � V <br /> SUITE/UNIT#: A 7 FLOOR M ADDITIONAL L CATION INFORMATION: <br /> TENANT/BUSINESS NAME(if non-residential): v #- 6G <br /> CONTACT INFORFAATION <br /> OWNER NAME: of D6 S r/G <br /> OWNER MAILING ADDRESS: STREEO1 d <br /> CITY �rC STATE ZIP g OL <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR COMPANY NAME: trCl /VI2 �G G�Nr'CI <br /> WA STATE CONTRACTOR LICENSE#( IML 0 Q h CITY OF EVERETT BUSINESS LICENSE 4(REQUIRED):/_f <br /> CONTRACTOR ADDRESS: STREET 77 91 Fjo E <br /> CIN u o STATE klq ZIP U <br /> 3 70 <br /> CONTRACTOR PHONE: O.•6VI 0,3 CONTRACTOR EMAIL: <br /> PRIMARY CONTACT: ❑OWNER CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: 366 <br /> S� CONTACT EMAIL: 2( <br /> //�� PLUMBING PERMIT INFORMATION <br /> VALUATION OF WORK:$ v0 f.! ASSOCIATED PERMIT#(if applicable): <br /> (Valuation shall Include the prevaUing 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: A Commercial ❑Accessory Structure <br /> DESCRIPTION OF WORK: <br /> rp <br /> IA)Uhr A�a�rs yule. sam� �fatik��ss <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)-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 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.,1 have reviewed this application and confirm the information contained herein is true and correct.Work done pursuant to this permit must comply wilh <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 1 comply with the State Contractors Law 16.27 RCW`and 296.200A WAC. <br /> City of Everett Official Use Only <br /> —�7 o2 3 PERMIT# V�✓ I^ �� <br /> Owner/ th ized Ag t gnature Date (Revised 4/21/2022) [J/ <br />