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EVERETT <br />WASHINOTON <br />PLUMBING PERMIT APPLICATION I <br />W <br />CITY OF EVERETT PERMIT SERVICES <br />SUBMITTAL INSTRUCTIONS: Drop off hard copy completed paper application to 3200 Cedar Street 2nd Floor Intake Drop Box. <br />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 <br />PARCEL #: <br />CITY <br />STATE ZIP <br />SUITE/UNIT M FLOOR M <br />ADDITIONAL LOCATION INFORMATION: <br />TENANT/BUSINESS NAME (if non-residential): <br />CONTACT INFORMATION <br />OWNER NAME: <br />OWNER MAILING ADDRESS: STREET <br />crrY <br />STATE ZIP <br />/�-�-- <br />OWNER PHONE: �(�2 5 ��7 6^ t� , / <br />OWNEREMAIL: <br />CONTRACTOR COMPANY NAME: <br />WA STATE CONTRACTOR LICENSE #(REQUIRED): <br />CITY OF VERETT BUSINESS LICENSE #(REQUIRED): <br />CONTRACTOR ADDRESS: STREET <br />CITY <br />STATE ZIP <br />CONTRACTOR PHONE: <br />CONTRACTOR EMAIL: <br />PRIMARY CONTACT: ❑ OWNER ❑ CONTRACTOR ❑ OTHER (Please Specify) <br />CONTACT NAME: <br />CONTACT PHONE: <br />CONTACT EMAIL: <br />PLUMBING PERMIT INFORMATION <br />VALUATION OF WORK: $ 36 C)o0 <br />ASSOCIATED PERMIT # (if applicable): <br />(Valuation shall include the preva0ing fair market value of all labor, materials, and equipment needed to complete the work, whether actually paid or not.) <br />BUILDING TYPE: ❑SFR ❑Townhouse )RDuplex <br />❑ADU ❑Multi -Family - # Units: []Commercial ❑Accessory Structure <br />DESCRIPTION OF WORK: —� v <br />PLUMBING PERMIT FIXTURE <br />COUNT (SCOPE OF WORK) <br />Fixture <br />Count <br />(Qty) <br />List of Fixtures <br />Fixture <br />Count <br />MIA <br />List of Fixtures <br />U11A <br />Backflow Prevention Device (Inside Building) -select devices below: <br />Fire Service: ❑DCDA, Domestic Service: ❑RPBA ❑DCVA <br />Shower, Tub, or Combo <br />Commercial Sink (3-compartment, prep, floor) <br />Clothes Washer <br />Residential Sink (kitchen, bath, bar) <br />Dishwasher <br />Utility Sink (laundry, mop) <br />Drinking Fountain <br />Toilet <br />Floor Drain <br />Urinal <br />77 <br />Hose Bibb <br />Waste/Water Pipe Repair <br />Ice Maker <br />Water Service Line (Behind meter, private side) <br />Grease Interceptor <br />Water Valves/Fixtures <br />Sand/Oil Interceptor <br />Water Heater - Electric <br />Medical Gas <br />Water Heater - Gas <br />Roof Drains <br />Other (List Type): <br />Sewage Ejector Pump/Sump Pump <br />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 file <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# quo/ (^�� <br />Date (Revised 412112022) U <br />