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IN= 111If) ECEINEI <br /> 1..), <br /> PLUMBING PERMIT APPLICATIO MAR 0 8 2023 <br /> EVERETT SUBMITTAL CITY OF EVERETT PERMIT SERVICES <br /> INSTRUCTIONS: Drop off hard copy completed paper application to 32U 3 ramp c •I,.'Eater Box. <br /> yKpr t <br /> WASHINGTON CONTACT INFORMATION:(P)425.257.8810 I(E)everetteps@everettwa.gov I(W ew,na.goeF 1 <br /> 1f' fit ervicc3 <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET A- �.j.}�� uC five PARCEL#: fU� <br /> CITY Eva f'�1 STATE kI, ZIP _1� ZOS <br /> SUITE/UNIT#: FLOOR#: 1 ADDITIONAL LOCATION INFORMATION: <br /> TENANT/BUSINESS NAME(if non-residential): <br /> ( q CONTACT INFORMATION yNF�,ORMATION <br /> OWNER NAME: O F u3 .Ff 11"ILY Y( 1 / T <br /> OWNER MAILING ADDRESS: STREET Lj3 VEN l.-Id��Tl utc <br /> CITY P.Al v E l! STATE WA ZIP 1 621)3 <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR COMPANY NAME: 5 7 7p _ Lu ma <br /> WA STATE CONTRACTOR LICENSE#(I p 'lq p go..CITY OF EVERETT BUSINESS LICENSE#(REQUI ED):7 <br /> CONTRACTOR ADDRESS: STREET I5c.al'l % iil(L.1 _121) <br /> 2 f/���C�� CITYS'Nb t,1flI STATE I' ZIP �E IIV <br /> CONTRACTOR PHONE:3 5b —'t1 6 - CONTRACTOR EMAIL: � <br /> PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR ❑OTHER(Please Specify)((3�(LE C �7�:.t1 Z.erplumb1 N1(.y,COM <br /> CONTACT <br /> fNAME: <br /> � CONTACT PHONE:4/LG,-'7 r-;S - 1st/ <br /> �/�i 1 [�G� CONTACT EMAIL:C1C71C iJ C� jet zet'pl urY1io1✓)tw•LC►l 1 <br /> PLUMBING PERMIT INFORMATION <br /> VALUATION OF WOR • I Oi COO ASSOCIATED PERMIT#(if applicable): ['r3 7J, 3 2- <br /> (Valuation shall include the pr ailing air market value of all I r,materials,and equipment needed to complete the work,whether actually p,.,u or not.) <br /> BUILDING TYPE: FR ❑Townhous ❑Duplex ❑ADU ❑Multi-Family-#Units: ❑Commercial ❑Accessory Structure <br /> DESCRIPTION OF WO • <br /> K 'nwo._ rc - 2 17 ftr ` L��s �r', M I t O 2 c i <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: 2 Shower,Tub,or Combo <br /> Fire Service:❑DCDA, Domestic Service:❑RPBA❑DCVA Commercial Sink(3-compartment,prep,floor) <br /> I Clothes Washer 1t Residential Sink(kitchen,bath,bar) <br /> 1 Dishwasher Utility Sink(laundry,mop) <br /> Drinking Fountain fi 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: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 /> Cjitt:6- 2-4-A--- <br /> -r 4 •13. 3 •2_3 53oQ <br /> Owner/Authorized Agent Signature Date (Re sed 2/8/2021) <br />