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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)425.25T8810 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 ') (� th PARCEL M 00 `/35 3 f-1 Oa 00 <br /> CITY U�(�� STATE ZIP G <br /> SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION: <br /> TENANT/BUSINESS NAME (if non-residential): <br /> CONTACT INFORMATION <br /> OWNER NAME: <br /> OWNER MAILING ADDRESS: STREET 5 L r <br /> CITY t)eu :! STATE �CA Zip I .5 <br /> OWNER PHONE: 1( 61 OWNER EMAIL: S MI l-14 6u r6l�+I • C d""', <br /> CONTRACTOR COMPANY NAME: Ll 10 (—� ( tM s I o;q 5 L L <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): j(� S �( CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): Ot.( �95 )CTJ <br /> CONTRACTOR ADDRESS: STREET �(� N`� Q <br /> CITY u e STATE ZIP (J'Z S <br /> CONTRACTOR PHONE: &/d! 3 - CONTRACTOR EMAIL: 111>0 1 ci Cr r /4p1lb <br /> PRIMARY CONTACT: OWNER ❑CONTRACTOR ❑OTHER (Please Specify) <br /> CONTACT NAME: CONTACT PHONE: 'N CJ 5 3 1 <br /> CONTACT EMAIL: S AA I f�l Ln ' CI � )C (�( I . (v✓VL <br /> PLUMBING PERMIT INFORMATION <br /> VALUATION OF WORK: $ 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 Nbuplex ❑ADU ❑Multi-Family-#Units: ❑Commercial ❑Accessory Structure <br /> DESCRIPTION OF WORK: <br /> move lo(a�f�n �f faile+� 5�� 4s)actaled pluP4bl,ng . <br /> Iviave lo(atiDn c� washl' iRac%lile og'/ 'J i >,c/afe plao'bl,I� U <br /> PLUMBING PERMIT FIXTURE COUNT (SCOPE OF WORK) <br /> Fixture Fixture <br /> Count List of Fixtures Count List of Fixtures <br /> (Qhr) (Q <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 /> I Clothes Washer dC ,: Residential Sink(kitchen, bath, bar) <br /> Dishwasher Utility Sink(laundry, mop) <br /> Drinking Fountain Toilet <br /> Floor Drain Urinal <br /> Hose Bibb i Waste/Water Pipe Repair <br /> Ice Maker Water Service Line(Behind meter,private side) <br /> Grease Interceptor Water Vatves/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 I 10ther(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.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 1 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 Agipt'8ignature Date (Revised 21812021) <br />