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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)everetteps@everetlwa.gov I(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET q2 <br /> ,I 4qo),+ .4,{ PARCEL#: 03 c,-10 a 'LOOU <br /> CITY V(y4 STATE W ZIP Z <br /> SUITE/UNIT M FLOOR M ADDITIONAL LOCATION INFORMATION: <br /> TENANT/BUSINESS NAME(if non-residential): <br /> CONTACT INFORMATION <br /> OWNER NAME: C <-n( t✓ <br /> OWNER MAILING ADDRESS: STREET fIci Z 0 h LE <br /> CITY /' STATE f� ZIP L(> <br /> OWNER PHONE: j S )3) OWNER EMAIL: S (,!2C1YL✓2/ tie M a m' / G•" <br /> CONTRACTOR COMPANY NAME: G n Y— <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): <br /> CONTRACTOR ADDRESS: STREET <br /> CITY STATE ZIP <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> PRIMARY CONTACT: OWNER ❑CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: II CONTACT PHONE: 3) <br /> CONTACT EMAIL: <br /> PLUMBING PERMIT INFORMATION <br /> VALUATION OF WORK:$ ASSOCIATED PERMIT#(if applicable): 6 7 o 0-j"y <br /> (Valuation shall include the prevailing fair market value of all labor,materials,and equipment needed to complete the work,whether actually pald or not.) <br /> BUILDING TYPE: SFR ❑TowJnJhouse ❑Duplex ❑AD/U ❑Multi-Family-#Units: ❑Co/mmercial ❑Acc/eessory/Structure <br /> DESCRIPTION f� <br /> e WORK' A I pl YOU/tl ct vid L G, v N J ryP <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: 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 1 Utility Sink(laundry,mop) <br /> Drinking Fountain 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.,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./am the owner,or l 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 /> z 3 t�23W - 001 <br /> O r/Authorized Agent gnature Da a (Revised 21812021) <br />