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PLUMBING PERMIT APPLICATION <br />EVERETT <br />WASHINGTON <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 6 / PARCEL M <br />c� <br />CITY r T STATE Lti ,' I ZIP C( 7-0 8 <br />SUITE/UNIT M FLOOR M ADDITIONAL LOCATION INFORMATION: <br />TENANT/BUSINESS NAME (if non-residential): <br />CONTACT INFORMATION <br />OWNER NAME: L I t3 ( rll- rV <br />OWNER MAILING ADDRESS: STREET 90 17 S, A--U <br />CITY ) STATE �J ZIP 2-08 <br />OWNER PHONE: y 2S 73 Z Y) 3 <br />OWNER EMAIL: kp }I L r ci 41\1 <br />CONTRACTOR COMPANY NAME: <br />WA STATE CONTRACTOR LICENSE #(REQUIRED): <br />CITY OF EVERETT BUSINESS LICENSE #(REQUIRED): <br />CONTRACTOR ADDRESS: STREET <br />crTY STATE ZIP <br />CONTRACTOR PHONE: <br />CONTRACTOR EMAIL: <br />PRIMARY CONTACT: ❑ OWNER ❑ CONTRACTOR ❑ OTHER (Please Specify) <br />CONTACT NAME: <br />C) W NJ-P� <br />CONTACT PHONE: <br />CONTACT EMAIL: <br />PLUMBING PERMIT INFORMATION <br />VALUATION OF WORK: $ ASSOCIATED PERMIT # (if applicable):_ - <br />(Valuation shall Include the p evading 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 ❑ADU []Multi -Family - # Units: ❑Commercial ❑Accessory Structure <br />DESCRIPTION OP WORK: <br />PLUMBING PERMIT FIXTURE COUNT (SCOPE OF WORK) <br />Fixture <br />Count <br />(Qty) <br />List of Fixtures <br />Fixture <br />Count <br />(Qty) <br />ListofFixtures <br />Backflow Prevention Device (inside Building) -select devices below: <br />Fire Service: ❑DCDA, Domestic Service: ❑RPBA ODCVA <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 />Hose Bibb <br />WastefWater 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 I <br />10ther <br />(List Type): <br />Sewage Ejector Pump/Sump Pump 1 <br />1 <br />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 1 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 1,aw-1 �7 RCW and 296.200A WAC. <br />1 City of Everett Official Use Only <br />PERMIT # <br />Owner/Autfiorized Agent Signature Date (Revised 412112022) <br />