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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)PermitServices@everettwa.gov I(W)everettwa.gov/permits <br /> (Blue or Black Ink Oiify Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET <br /> �_ L� PARCEL#: <br /> CITY Vip- STATE �J\/ ZIP I <br /> SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION: <br /> TENANT/BUSINESS NAME(if non-residential): <br /> t� CO TACT <br /> (INFORMATION <br /> OWNER NAME: A 1k, r <br /> OWNER MAILING ADDRESS: STREET <br /> CITY �1�� r STATE ZIP <br /> OWNER PHONE: ' ��C OWNER�EMAIL: <br /> CONTRACTOR COMPANY NAME: I� asl/`�� S • <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED):' PEP/Pq CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): <br /> CONTRACTOR ADDRESS: STREET Pp — ® R\ 2 <br /> CITY Q STATE ZIP <br /> CON TRACTOR PHONE: ��— CONTRACT OR EMAIL: <br /> PRIMARY CONTACT: ❑OWNER CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: 2c3 g - 296 9" <br /> CONTACT EMAIL: �Vbe..Q • 7CL(tn�(>( /2(2 C4'A <br /> PLUMBING.'PER MIT.INFOR TION <br /> VALUATION OF WORK:$ �ZSa ASSOCIATED PERMIT#(if applicable): <br /> (Valuation shall Include the prevailing fair market value of all labor,materials,and equipment needed to complete the work,Whetheraclually paid or not.) <br /> BUILDING TYPE:• SFR ❑Townhouse ❑Duplex ❑ADU ❑Multi-Family-#Units: ❑Commercial ❑Accessory Structure <br /> DESCRIPTION. <br /> WORK: ` IZ`A ` r, / Q 6y , <br /> l � l2�aC�•� ,r�a,�s�T-�z��l„ (�-�,�- 1L L1 t.-U-' <br /> m s �M <br /> PLUMBING PERMIT FIXTURE COUNT (SCOP. OF WORK) <br /> Fixture Fixture <br /> Count List of Fixtures Count List of Fixtures <br /> My) My) <br /> Backflow Prevention Device(Inside Building)-select devices below: ower,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 Taller <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.1 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 /> Al2- 015 <br /> Owner/Authorized Agent Slgna ur Date (Revised 412112022) - <br />