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g r DLL.. tANG PERM@ ' AP'LDC Y T <br /> ®� CITY OF EVERETT PERMIT SERVICES <br /> EVERETT T SUBMITTAL 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/permits <br /> {Bkie or Black ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: ^s:REE A\1) 74th ST SE PARCEL#: 00398700200201 <br /> l EverettWA 98203 <br /> ciTv STATEziP <br /> JSUITEIUNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION: , <br /> {TENANTIBUSINESS NAME(if non-residential). <br /> CONTACT INFORMATION <br /> DOWNER NAME:Haack Brothers Homes 1 <br /> )OWNER MAILING ADDRESS: STREET3922 87th AVE NE <br /> C,7y Marysville STATE WA ZIP 98270 <br /> OWNER PHONE:425-290-2429 OWNER EMAIL:joel@haackbrothers.com <br /> CONTRACTOR COMPANY NAME: C \ ) -C '' r( �? :,..„,1,--,�--,` ., a` <br /> 'WA STATE CONTRACTOR LICENSE#(REQUIRED):I ) j 7�'7'7 I { CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): (0 6j '2_,I, <br /> •CONTRACTOR ADDRESS: STREET <br /> /�() I L-`y�CP Fin 1 ' .l J/�f y�(y <br /> CITY rO WI E Vo. Y\O STATE 1 A)iq ZIP' L i�e'1`-5 <br /> (CONTRACTOR PHONE:425-290-2429 CONTRACTOR EMAIL:joel@haackbrothers.com <br /> PRIMARY CONTACT: ❑OWNER I CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: /+ CONTACT PHONE:425-290-2429 <br /> Joe Haack CONTACT EMAIL:joel@haackbrothers.com <br /> ( PLUMBING PERMIT INFORMATION <br /> VALUATION OF WORK:$ 1 "1 , (n) 0 ASSOCIATED PERMIT#(if applicable): <br /> i(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: ❑SFR ❑Townhouse ❑Duplex OADU ❑Multi-Family-#Units: ❑Commercial ❑Accessory Structure <br /> DESCRIPTION OF WORK:Plumb new SFR <br /> i <br /> PLUMBING PERMIT FIXTURE Co.UNT(SCOPE OF WORK) <br /> Fixture Fixture <br /> Count List of Fixtures Count List of Fixtures <br /> (QtY) (Qly) <br /> Backflow Prevention Device(Inside Building)-select devices below: 4 Shower,Tub,or Combo <br /> Fire Service.ODCDA, Domestic Service:ORPBA DDCVA Commercial Sink(3-compartment,prep,floor) <br /> 1 Clothes Washer 2 Residential Sink(kitchen,bath,bar) <br /> 1 Dishwasher i Utility Sink(laundry,mop) <br /> Drinking Fountain 3 Toilet <br /> Floor Drain Urinal <br /> 2 Hose Bibb Waste/Water Pipe Repair <br /> Ice Maker 1 Water Service Line(Behind meter,private side) <br /> { Grease Interceptor Water Valves/Fixtures <br /> i Sand/Oil Interceptor 1 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 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 /> ..., 4r PERM( , <br /> /°f q1� 7, 0 .2 O Doi <br /> Owner/Authorized Agent Signature Date (Revised 4/21/2022) <br />