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mom <br /> voi PIAIVIBING PERMIT APPLICAllipN <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 I(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET 3(Q 1 C R.i 01,ot Pet, PARCEL#: OOL S I`J OCR <br /> CITY de.r(., STATE A + \ ZIP 1 U L <br /> SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION: <br /> TENANT/BUSINESS NAME(if non-residential): <br /> CONTACT INFORMATION <br /> OWNER NAME: 1-04.('e(i + K.ot►l Gt- Pc c <br /> OWNER MAILING ADDRESS: STREET Sa.A.t_ a F03. Q4&(re Sc, <br /> CITY I� I STATE 11 ZIP <br /> OWNER PHONE: L./X.-Li - g( qO OWNER EMAIL: )pale S Qbi{ @(404'64et;1 . (rj <br /> CONTRACTOR COMPANY NAME: ShOvt)4in e, I-ive. ►c e/AO V01-4101ti. <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): SHOWTI-}3:B01)A F CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): 6-oy <br /> CONTRACTOR ADDRESS: STREET I61 S.I, N f.,e,tSC S}. s*t t 0 1- <br /> CITY Mc t fps, STATE WA ZIP R sCONTRACTOR PHONE: 4l-5`- '436- 4I CONTRACTOR EMAIL:RWSSeLle.Slnowfirneha,Mere►'oVa.'}l OA•cam. <br /> PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR OTHER(Please Specify)DCci:ql PA <br /> CONTACT NAME: CONTACT PHONE: C12- -tic( el CIO <br /> Gete CONTACT EMAIL:5e,(.Gvt A a.(t <br /> '{.7.{A- s,`i c o0.4.Qaat t� • cow. <br /> PLUMBING PERMIT INFORMATION <br /> VALUATION OF WORK: $ 5Q, 000 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:XSFR ❑Townhouse ❑Duplex ❑ADU ❑Multi-Family-#Units: ❑Commercial ❑Accessory Structure <br /> DESCRIPTION OF WORK: <br /> (1, ' re o oe,l avtol c ov,ot; ovn.,-e L frart± zw a d d h' & <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: t 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 t 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 Cont actors Law 18.27 RCW and 296.200A WAC. <br /> 41/04- City of Everett Official Use Only <br /> PERMIT# <br /> Owner/Authorized A nt Signature ate (Revised 4/21/2022) <br />