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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[(E)PermitServices@everettwa,gov I(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET st' /n7 PARCEL#: <br /> `5 r� ✓, STATE ' .JFq-- ZIP <br /> SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION: <br /> TENANT18USINESS NAME(if non-residential): TUT <br /> CONTACT INFORMATION <br /> OWNER NAME: <br /> OWNER MAILING ADDRESS: STREET <br /> CITY r STATE ZIP �I <br /> OWNER PHONE: :j4a6,—e 2-1d- <br /> -C 1OWNER EMAIL: <br /> CONTRACTOR COMPANY NAME: <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED);! CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): U <br /> �Q <br /> CONTRACTOR ADDRESS: srReEr�tT J jZ� J <br /> CITY cf / STATE �� ZIP <br /> CONTRACTOR PHONE: �)(,G QZ CONTRACTOR EMAIL: �jQ i 9z),- <br /> PRIMARY CONTACT: 17 OWNER f CONTRACTOR D OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: <br /> f�s CONTACT EMAIL: <br /> PLUMBING PERMIT INFORMATION <br /> VALUATION OF WORK:$ U QUfr, ASSOCIATED PERMIT#(ifapplicable): B 312' 0-31 <br /> (Valuation shall include the prevaging fair nfarket value of all labor,materials,and equipment needed to complete the work,whether acteally paid or not.) <br /> BUILDING TYPE: ©SFR ❑Townhouse ©Duplex ©ADU E]Multi-Family-#Units: SCommercial ©Accessory Structure <br /> DESCRIPTION OF WORK. <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 ommercial Sink(3-compartment,prep,floor) <br /> MA in W- <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 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.f am the owner,or 1 am authorized by the owner of this property to perform the work for which application is mads, <br /> and 1 comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> Z � �y // PERMIT# <br /> AV �G i�G / / ����7 �"t v M3 <br /> OwnerfAuthorized Agent Signature Da (Revised 4/21/2022) <br />