10201 1ST DR SE 2025-05-13 - Laserfiche WebLink

PLUMBING PERMIT APPLICATION EVERETT SUBMITTAL INSTRUCTIONS: OF EVERETT PERMIT SERVICES S:Drop off hard copy completed paper application to 3200 Cedar Street 2nd Floor Intake Drop Box. WASHINGTON CONTACT INFORMATION:(P)425.257.8810 1(E)everetteps@everettwa.gov I(W)everettwa.gov/permits (Blue or Black Ink Only Please) PROJECT SITE INFORMATION PROJECT SITE ADDRESS: STREET PARCEL* CITY STATE ZIPZV SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION: TENANT/BUSINESS NAME(if non-residential): CONTACT INFORMATION OWNER NAME: 1 V1 C�7� OWNER MAILING ADDRESS: STREET � CITY STATE w ZIP Vb OWNER PHONE: 42S d OWNER EMAIL: F � r T �01ti. CONTRACTOR COMPANY NAME: WA STATE CONTRACTOR LICENSE#(REQUIRED): CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): CONTRACTOR ADDRESS: STREET CITY STATE ZIP CONTRACTOR PHONE: CONTRACTOR EMAIL: PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR ❑OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: CONTACT EMAIL: PLUMBING PERMIT INFORMATION VALUATION OF WORK:$ 1 D t*-� Z-CC O ASSOCIATED PERMIT#(if applicable): (Valuation shall include the prevailing fair market value of all labor,materials,and equipment needed to complete the work,whether actually paid or not.) BUILDING TYPE: H!§FR ❑Townhouse ❑Duplex ❑ADU ❑Multi-Family-#Units: ` ❑Commercial ❑Accessory Structure DESCRIPTION OF WORK: / ,—,. 5( p��K SAM( QS�Mr �� VV-,v� o cam, 1 PLUMBING PERMIT FIXTURE COUNT (SCOPE OF WORK) Fixture Fixture Count List of Fixtures Count List of Fixtures (Qty) (Qty) . Backflow Prevention Device(Inside Building)-select devices below: 1 Shower,Tub,or Combo Fire Service:❑DCDA, Domestic Service:❑RPBA❑DCVA Commercial Sink(3-compartment,prep,floor) Clothes Washer Residential Sink(kitchen,bath,bar) Dishwasher Utility Sink(laundry,mop) Drinking Fountain Toilet Floor Drain Urinal Hose Bibb Waste/Water Pipe Repair Ice Maker Water Service Line(Behind meter,private side) Grease Interceptor Water Valves/Fixtures Sand/Oil Interceptor Water Heater-Electric Medical Gas Water Heater-Gas Roof Drains Other(List Type): Sewage Ejector Pump/Sump Pump Other(List Type): ACKNOWLEDGEMENT.,l have reviewed this application and confirm the Information contained herein is true and correct.Work done pursuant to this permit must comply with 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 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, and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. City of Everett Official Use Only PERMIT# - r kC aoa3 1i3v - O-QvnerlAuthorized Agent Signature Date (Revised 21812021)