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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 Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET ``Dl CS+C(AAC.Vie,vJ E, i l PARCEL' #: 005q 6 2-OO-4OdaC)O <br /> p.� W <br /> CITY EvU STATE ll \ ZIP <br /> SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION: <br /> TENANT/BUSINESS NAME(if non-residential): <br /> CONTACT INFORMATION <br /> OWNER NAME: CaI�G aM. L <br /> OWNER MAILING ADDRESS: STREET SCI+t� a�, � 0.d•r�re SS <br /> CITY STATE ZIP <br /> OWNER PHONE: Lig( . (> OWN"ER EMAIL: �t`a�e Oet`Gtv►C.. ��{lAvw�� . <br /> CONTRACTOR COMPANY NAME: 5►L17 ticwt, tcallod`o� �1avL <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): 6%)Lf <br /> CONTRACTOR ADDRESS: STREET J ; sl"?_ 10S <br /> CITY Mom-of— STATE �/t// 7 ZIP <br /> CONTRACTOR PHONE: Lf -5- 9-)j6 - � CONTRACTOR EMAIL:2V (,(( 95h0IIV f A-eGbW At(*10Vg7tic-%/L ,COvw <br /> PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR P4OTHER(Please Specify) 'Des"�nor <br /> CONTACT NAME: _ 0 CONTACT PHONE: q7<'_ �?l - �rt qQ <br /> tom- CONTACT EMAIL: <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: FIR ❑Townhouse ❑Duplex DU ❑Multi-Family-#Units: ❑Commercial ❑Accessory Structure <br /> DESCRIPTION OF'WORK: <br /> 1V\+t ',0\r ceV�Aod"E,l, bAsePAevt,-F- Abed CoALfe/r5;0\& f avlt:(pc.k+;)m W due,�aA o� o.+a,►75 <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. 3 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 /> a- Dishwasher 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: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.I am the owner,or/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 /> Od4AA �', �O PERMIT# <br /> b�vner/Authorizod Ager Signature Dat (Revised 4,21/2022) <br />