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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) everetteps@everettwa.gov I (W) everettwa.gov/permits <br />(Blue or Black Ink Only Please) PROJECT SIT(E� INFORMATION <br />PROJECT SITE ADDRESS: STREET 3ct0�' rf'CGIf<f� ( L1G PARCEL #: 6y1()530W 363SciCr <br />CITY EJC-Y_� STATE t.'i1 ZIP GtV00 <br />SUITE/UNIT #: FLOOR #: ADDITIONAL LOCATION INFORMATION: <br />TENANT/BUSINESS NAME (if non-residential): <br />CONTACT INFORMATION <br />n� <br />OWNER NAME: GA. <br />OWNER MAILING ADDRESS: STREET 39044 FeC&-tc( <br />CITY &j e—x-* STATE `T zip <br />OWNER PHONE: Liq - /5 ly.5 <br />OWNER EMAIL: (Ct/_Lk-m-vte <br />CONTRACTOR COMPANY NAME: 0,4 nor <br />WA STATE CONTRACTOR LICENSE #(REQUIRED): <br />CITY OF EVERETT BUSINESS LICENSE #(REQUIRED): <br />CONTRACTOR ADDRESS: STREET <br />CITY STATE ZIP <br />CONTRACTOR PHONE: <br />CONTRACTOR EMAIL: <br />PRIMARY CONTACT: IQOWNER ❑ CONTRACTOR ❑ OTHER (Please Specify) <br />CONTACT NAME: a <br />1 'L �A� <br />CONTACT PHONE: [� Z 49 -�4'gS <br />CONTACT EMAIL: a <br />rCv._llcvYNt� cew s- �T <br />PLUMBING PERMIT INFORMATION <br />VALUATION OF WORK: $ (S� <br />�1 <br />ASSOCIATED PERMIT # (if applicable): 13 30-l0(0 <br />(Valuation shall include the prevailing fair market value of all labor, materials, and equipment needed to complete the work, whether actually pail or not.) <br />BUILDING TYPE: ❑SFR ❑Townhouse ❑Duplex NADU ❑Multi -Family - # Units: ❑Commercial ❑Accessory Structure <br />DESCRIPTION OF WORK: <br />(,(,Ipt u;ke— W rke_ J (ZaI L- IA SLCk," 1 <br />cud od& 1<,4cb,--A SrrJk .` &SIoAst4� <br />PLUMBING PERMIT FIXTURE <br />COUNT (SCOPE OF WORK) <br />Fixture <br />Count <br />(Qty) <br />List of Fixtures <br />Fixture <br />Count <br />(Qfy) <br />List of Fixtures <br />Backflow Prevention Device (Inside Building) -select devices below: <br />Fire Service: ❑DCDA, Domestic Service: ❑RPBA ❑DCVA <br />1 <br />Shower, Tub, or Combo <br />Commercial Sink (3-compartment, prep, floor) <br />Clothes Washer <br />3 <br />Residential Sink (kitchen, bath, bar) <br />j <br />Dishwasher <br />Utility Sink (laundry, mop) <br />Drinking Fountain <br />t <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: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 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 />Owner/Authorized <br />Date <br />City of Everett Official Use Only <br />PERMIT#1 5;1-310 — 0�0 <br />(Revised 21812021) <br />