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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 I(E)everetteps@everettwa.gov I(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET16 ,/ ' L L.fI Wfki kve PARCEL#: <br /> CITY lVl""V STATE ,14 ZIP `a (.CY- <br /> SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION: <br /> TENANT/BUSINESS NAME(if non-residential): <br /> CONTACT INFORMATION <br /> OWNER NAME: DEA )SE �t't-LDS <br /> OWNER MAILING ADDRESS: STREET Z"/O 4 1;/\ 11 Noll p''( <br /> CITY y STATE Vll,l ZIP 9 e W- <br /> OWNER PHONE:42 P� " 3 ) OWNER EMAIL: 0,41 h i-nS t2(1 I . Com <br /> CONTRACTOR COMPANY NAME: ,- y. p I U Yn b IkA <br /> h <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED):1X .-+Zee*7 1O1CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): l t <br /> CONTRACTOR ADDRESS: STREET Cj(,I Ilck 1^rw /n� + <br /> CITY J' TIt�tU 1(1 M1 S STATE U�T ZIP Q a 2 <br /> CONTRACTOR PHONE: 36-5G8-c-11 S 4 CONTRACTOR EMAIL:b4l(L-@ SekZ.-er`piombin90 corn <br /> PRIMARY CONTACT: ❑OWNER CaCONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE:4ZG'_ —4560:7 <br /> JCE ����T�jt�1Z CONTACT EMAIL: Uhe-t5.1-06-ph ex-, con 5+ruc+icrt hcr�rnc�`tI <br /> PLUMBING PERMIT INFORMATION Conk <br /> VALUATION OF WORK:$ 3,OOO-" ASSOCIATED PERMIT#(if applicable): B`LZt 0 •- 03( <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 VIQDU ❑Multi-Family-#Units: ❑Commercial ❑Accessory Structure <br /> DESCRIPTION OF WORK: <br /> gouc-tf --IJ,i it T2tm5 0 tn'+p-(-(_ ViUm61ncc .for bc1/45 Pr Duc".nd rerr; cLd 06 <br /> UPbtu(rs .V-ck_er‘<f 2 X3..hhr'�cmS <br /> PLUMBING PERMIT FIXTURE COUNT (SCOPE OF WORK) <br /> Fixture Fixture <br /> Count List of Fixtures Count List of Fixtures <br /> (QtY) (Qfy) <br /> Backflow Prevention Device(Inside Building)-select devices below: 3 Shower,Tub,or Combo <br /> Fire Service:❑DCDA, Domestic Service:❑RPBA❑DCVA Commercial Sink(3-compartment,prep,floor) <br /> 11„ Clothes Washer Residential Sink(kitchen,bath,bar) <br /> 2, Dishwasher Utility Sink(laundry,mop) <br /> Drinking Fountain 3 Toilet <br /> Floor Drain Urinal <br /> Hose Bibb Waste/Water Pipe Repair <br /> Z Ice Maker Water Service Line(Behind meter,private side) <br /> Grease Interceptor Water Valves/Fixtures <br /> Sand/Oil Interceptor la Water Heater-Electric <br /> Medical Gas Z Water Heater-Gas <br /> Roof Drains Other(List Type): <br /> Sewage 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# , ,� <br /> Owner/Authorized Agent Signature Date (Revised 2/8/2021) <br />