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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) everefteps@everettwa.gov I (W) everettwa.gov/permits <br />(BlueorBlack Ink Only Please) PROJECT SITE INFORMATION <br />PROJECT SITE ADDRESS: STREET PARCEL #: <br />`A <br />CITY G y y STATE VA ZIP Q <br />SUITE/UNIT #: FLOOR #: ADDITIONAL LOCATION INFORMATION: <br />TENANTIBUSINESS NAME (if non-residential): <br />CONTACT INFORMATION <br />OWNER NAME: -41"OvffD La Ly U/ 11PA R L S U <br />OWNER MAILING ADDRESS: STREET G` <br />CITY 10fflXLAA1b STATE ZIP 19 <br />OWNER PHONE: <br />OWNER EMAIL: tt 9 IG1 L LG. e0 <br />CONTRACTOR COMPANY NAME: a OVIR1,4101 <br />WA STATE CONTRACTOR LICENSE #(REQUIRED): p L OF EVERETT BUSINESS LICENSE #(REQUIRED): <br />CONTRACTOR ADDRESS: STREET lepZ V 10 <br />CITY R STATE ZIP 192 <br />CONTRACTOR PHONE: <br />CONTRACTOR EMAIL: <br />PRIMARY CONTACT: ❑ OWNER ❑ CONTRACTOR OTHER (Please Specify) C , <br />CONTACT NAME: :fAYI G' It <br />ICONTACT PHONE: <br />CONTACT EMAIL: <br />PLUMBING PERMIT INFORMATION <br />VALUATION OF WORK: $ p ASSOCIATED PERMIT # (if applicable): <br />(Valuation shall Include the preva�ing felr rket value of all moor, materials, and equlpmenl nee ed to complete the work, whetheractuelly paid or not.) <br />BUILDING TYPE: ❑SFR ❑Townhouse ❑Duplex ❑ADU ulti-FawilyjUnits: 3 ❑Commercial Structure <br />e❑Accessory <br />DESCRIPTION OF WORK: i� (J '*WASIli <br />' U Y <br />o� 40 <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 />List of Fixtures <br />Backgow 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 />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.: I have reviewed this application and confirm the /nformallon contained herein Is two and correct. Work done pursuant to this permit must comply with <br />current federal, state, and local law. The granting of a permit only authodzes approved work and no deviations therefrom. Deviations must first be authorized In writing from the <br />Building Official before being authorized under any circumstance. 1 am the owner, or am authorized by the owner of ihls property to perhorm 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 />2209 - Co <br />(Revised 21812021) <br />