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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)everetteps@everettwa.gov I(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) / PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET 1 p.. PARCEL#: <br /> �. CITY (/ STATE J4f ZIP <br /> URr�UMT : FLOOR#: ADDITIONAL LOCATION INFORMATION: <br /> TENANTIBUSINESS NAME(if non-residential): <br /> CONTACT INFORMATION <br /> OWNER NAME: (� t <br /> OWNER MAILING ADDRESS: STREET <br /> CITY STATE ZIP <br /> OWNER PHONE: — OWNER EMAIL: <br /> CONTRACTOR COMPANY NAME: yG <br /> WA STATE CONTRACTOR LICENSE#( �PP/ / '_©— CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): (52 <br /> CONTRACTOR ADDRESS: STREET 3 <br /> C" ilotlbl STATE ZIP <br /> CONTRACTOR PHONE: ! 5- - CONTRACTOR EMAIL: M p <br /> PRIMARY CONTACT: OWNER ❑CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: <br /> 2-C -5 CONTACT EMAIL: <br /> PLUMBING PERMIT INFORMATION <br /> VALUATION OF WORK: $ �ji U ASSOCIATED PERMIT#(if applicable): <br /> (Valuation shall include the prevailing 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 KADU ❑Multi-Family-#Units: ❑Commercial ❑Accessory Structure <br /> DESCRIPTION OF WORK: <br /> PLUN413ING 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/V1later 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 j2A/' <br /> Roof Drains Other(List Type): <br /> Seviage Ejector Pump/Sump Pump Other(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 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# �)-3 D <br /> c2 6::] <br /> O I d Agent nature Date (Revised 2/8/2021) <br />