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mom <br /> PLSBING PERMIT APPLICA14111N <br /> EVERETT SUBMITTAL CITY OF EVERETT PERMIT SERVICE:. <br /> INSTRUCTIONS: Drop off hard copy completed paper application to 3200 Cedar Street 2nd Floor Intake Drop Box. <br /> WASHINGTON CONTACT INFORMATION:(P)425-257-8810 I(E)PermitServices@everettwa.gov I(W)everettwa.gov/perrnits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET (1O I C c(A GI•Vie,vJ/Y% k/'t PARCEL#: OOS R 6 -DO Oda-O0 <br /> CITY EV`?l4-'E"t- STATE (4)1\ ZIP IN7'03 <br /> SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION: <br /> TENANT/BUSINESS NAME(if non-residential): <br /> CONTACT INFORMATION <br /> OWNER NAME: 1)i0, ,4_ C•llaln.an(�. <br /> OWNER MAILING ADDRESS: STREET € t4' ac, jc,cA A.h.otl•e.SS <br /> CITY STATE/ ZIP <br /> OWNER PHONE: 414- L{C‘( ((lb OWNER EMAIL: a..iav‘-e. otta,lr►t. c-ad tx (1\at.•1. Cow <br /> CONTRACTOR COMPANY NAME: Skorv-t-icv E{yAAt. (Zo r�o�w{ia,ti <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): S O�L1F CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): 6 2-09 9 <br /> CONTRACTOR ADDRESS: STREET 11,4 \ f /441.G.e, -1"� ( S .y <br /> CITY AAO'11r0� STATE telit ZIP 0 ?-1/ <br /> CONTRACTOR PHONE: 1-17-5.1. 9-36 - O4 f CONTRACTOR EMAIL:Ztsscji 5h0W-fi/v' Ci.WKCCevtOVettiCvL .COW\ <br /> PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR OTHER(Plefise Specify) 1eSi 1e C <br /> CONTACT NAME: & r p CONTACT PHONE: L 7.s"_ Li f( l q0 <br /> CONTACT EMAIL: IG.1,a @ fLko(dS,pt..tov„t,f/Il✓t . coo". <br /> PLUMBING PERMIT INFORMATION <br /> VALUATION OF WORK: $ O O 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: FR ❑Townhouse ❑Duplex DU ❑Multi-Family-#Units: ❑Commercial ❑Accessory Structure <br /> DESCRIPTION OF ORK: / <br /> Ik+ir;or ccm.0 LX, it)it.6eotevt+- Abje,orkve,rc :ovt / a. ot44 t citHi'v.. �,,r' �.loP,a+inrt o� s�a►r5 <br /> PLUMBING PERMIT FIXTURE COUNT (SCOPE OF WORK) <br /> Fixture Fixture <br /> Count List of Fixtures Count List of Fixtures �t 1 <br /> (QtY) (QtY) <br /> Backflow Prevention Device(Inside Building)-select devices below: 3 Shower,Tub,or Combo <br /> Fire Service:❑DCDA, Domestic Service:❑RPBA❑DCVA Commercial Sink(3-compartment,prep,floor) <br /> 'a— Clothes Washer 8 Residential Sink(kitchen,bath,bar) <br /> '- Dishwasher Utility Sink(laundry,mop) <br /> Drinking Fountain LI. 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 11 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,aid 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 Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> PERMIT# <br /> 1/0/WP-0 305- - <br /> ner/Authorized Age Signature Dat (Revised 4/21/2022) <br />