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PLUMBING PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> EVERETT 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 1(E)PermitServices@everettwa.gov I(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Pleaae)l PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET\\ L� �J�f� /'�c-\\ t✓c� PARCELM <br /> CITY STATE \,/A zip 2 U <br /> SUITEIUNIT#: t(30 FLOOR M ADDITIONALL LOCATION INFORMATION: <br /> TENANT/BUSINESS NAME(if non-residential): <br /> CONTACT INFORMATION <br /> OWNER NAME: <br /> OWNER MAILING ADDRESS: STREET <br /> CiTY STATE ZIP <br /> OWNER PHONE: 1O,WNER EMAIL: <br /> CONTRACTOR COMPANY NAME: Lvn4{0 I <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): FLO WCC P7gq ITY OF EVERETT BUSINESS LICENSE#(REQUIRED): <br /> CONTRACTOR ADDRESS: STREET C�U\C) r"\C-\r\(kA— 'P\c:.(�_ 't:yr5U <br /> CiTY C� TCl✓�� STATE W 4 zip 1 L5 <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: r'e-J- <br /> PRIMARY CONTACT: ❑OWNER Z�qCONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: L-125—S�Z—G\t�c` S <br /> CONTACT EMAIL: V ('�w ��j,y\ �i v'��c•ti y-e t— <br /> PLUMBING PERMIT INFORMATION <br /> VALUATION OF WORK:$ S O 1ASSOCIATED 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: ❑SFR ❑Townhouse ❑Duplex ❑ADU []Multi-Family-#Units: 14commercial ❑Accessory Structure <br /> DESCRIPTION OF WORK: C <br /> os�,- <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: Shower,Tub,or Combo <br /> Fire Service:❑DCDA, Domestic Service:ORPBA ODCVA Commercial Sink(3-compartment,prep,floor) <br /> Clothes Washer LA Residential Sink(kitchen,bath,bar) <br /> Dishwasher Utility Sink(laundry,mop) <br /> Drinking Fountain Toilet <br /> Floor Drain Urinal <br /> Hose Bibb WastefWater 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 p t 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 wr41 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 perforrie*TiYk®Fihf -�fC ET.T de, <br /> and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. p gkrg�t f v i CeS <br /> City of Ever tt a Cr us Y <br /> FPERMIT# <br /> AG�'�L q I I(,0 1 Z� <br /> Owner/Authorized Agent Signature Date (Revised 412112022) <br />