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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: STREET Cj Sr 4)12 6C PARCEL#: �2�j� <br /> CITY � (ZeA& STATE [ 'I ZIP � 0 <br /> SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION: <br /> TENANT/BUSINESS NAME(if non-residential): <br /> CONTACT INFORMATION <br /> OWNER NAME: <br /> 0-7,D fij !J (LE5 <br /> OWNER MAILING ADDRESS: STREET -y/��5! <br /> CITY/ L��Z e77— <br /> STATE U41;1,/ 21P t��j <br /> OWNER PHONE: �-( 7 OWNER EMAIL: 1 f k � �yyVlil�6� i C v✓Z <br /> CONTRACTOR COMPANY NAME: Re6i_ 0 Lv m i1% 06-17 <br /> WA STATE CONTRACTOR LICENSE#(REQUIREED): p ESTtItAF I CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): <br /> CONTRACTOR ADDRESS: STREET S V ) O a 1, � /v, <br /> CfIY �, �% r STATE (�( ZIP <br /> CONTRACTOR PHONE: 'b- l 50 CONTRACTOR EMAIL: �it-y SC/�Gl9vtil(31 ",ow,C r3 <br /> PRIMARY CONTACT: 51-OWNER ❑CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: <br /> AD y <br /> CONTACT EMAIL: <br /> PLUMBING PERMIT INFORMATION <br /> VALUATION OF WORK:$ s00. v� ASSOCIATED PERMIT#(if applicable): <br /> (Valuation shall include the prevailing fair fnarket 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 OFWORK: <br /> PLUMBING PERMIT FIXTURE COUNT (SCOPE OF WORK) <br /> Fixture Fixture <br /> Count List of Fixtures Count List of Fixtures <br /> (Qty) (Qt) <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 WastefWater 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.•l 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 ermit only authorizes approved work and no deviations therefrom.Deviations must first be authorized in writing from the <br /> Building Oficial before being authorized under a fc mstance.f am the owner,or 1 am authorized by the owner of this property to perform the work for Which application is made, <br /> and 1 comply with the Statntractors R and 296.200A WAC. <br /> City of Everett Official Use Only <br /> PERMIT# <br /> �, 3�1 ?-� Lg � � � , �5� <br /> Own er/Autho 'ze" n Sig- ti irk Date (Revised 4/21/2022) <br />