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PLUMBING PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> E V E R E T T SUBMITTAL 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@everetlwa.gov I(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET PARCEL#: <br /> CITY STATE ZIP <br /> SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION: <br /> TENANT/BUSINESS NAME(if non-residential): <br /> CONTACT INFORMATION <br /> OWNER NAME: <br /> OWNER MAILING ADDRE STREET (� <br /> CITY Q STATE ZIP <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR COMPANY NAME: <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): ^� CITY OF EVE T BUSINESS LICENSE#(REQUIRED): lG <br /> CONTRACTOR ADDRESS: STREET <br /> CITY STATE W.>� ZIP <br /> CONTRACTOR PHONE: Z• CONTRACTOR EMAIL:-- o( O i <br /> '.& <br /> -._.... ... .... -....__.. .... _ z <br /> PRIMARY CONTACT: ❑OWNER ACONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: <br /> CONTACT EMAIL: <br /> PLUMBING PERMIT INFORMATION <br /> 0 <br /> VALUATION OF WORK: ASSOCIATED PERMIT#(if applicable): <br /> (Valuation shall Include the 2rev ailing fair ma et value of all labor,materials,and equipment needed to complete the work,whether actually paid or not.) <br /> BUILDING TYPE: FR ❑Townhouse ❑Duplex ❑ADU ❑Multi-Family-#Units:` ❑Coommmercial ❑Accessory Structure <br /> DESCRIPTION O WORK: t-- bC_Ck+C' ` <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 lWater Heater-Gas <br /> Roof Drains 10ther(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 done pursuant to this permit must comply will? <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 el I hor' d under any circumstance.1 am the owner,or I am authorized by the ownerof this property to perform the work for which application Is made, <br /> ZOwnerlAuth <br /> ts?the State Co ractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> PERMIT# V .1 2 <br /> f <br /> azed AgentSlg ature Date (Revised 2/8/2021) <br />