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PLUMBING PERMIT APPLICATION <br /> EVERETT SUBMITTAL INSTRUCTIONS: <br /> OF EVERETT PERMIT SERVICES <br /> S: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 Please) PROJE <br /> CT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET /�'t \JQ_ lj(� PARCEL#: (, <br /> CITY i e_++_ STATE wt ZIP j� ♦� <br /> SUITE/UNIT M FLOOR M ADDITIONAL LOCATION INFORMATION: <br /> TENANT/BUSINESS NAME(if non-residential): <br /> CONTACT INFORMATION <br /> OWNER NAME: trVl� �L S O <br /> OWNER MAILING ADDRESS: STREET L Ca Ave— <br /> CITY { g <br /> � STATE `(,/ ZIP dVQ I) <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR COMPANY NAME: <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): <br /> CONTRACTOR ADDRESS: STREET <br /> CITY STATE ZIP <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> PRIMARY CONTACT: ER ❑CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: <br /> CONTACT EMAIL: <br /> PLUMBING.PERMIT.INFORMATION 11 ` <br /> VALUATION OF WORK: $ U)vo . 00 ASSOCIATED PERMIT#(if applicable): t <br /> (Valuation shall Include the prevailing fair market value of all labor,materials,and equipment needed to complete the work,vkrether actually paid or not.) <br /> BUILDING TYPE: ❑SFR ❑Townhouse ❑Duplex ❑ADU ❑Multi-Family-#Units: ❑Commercial ❑Accessory Structure <br /> DESCRIPTION OF WORK: <br /> _PLUMBING PERMIT FIXTURE COUNT (SCOPE OF WORK) <br /> Fixture Fixture <br /> Count List of Fixtures Count List of Fixtures <br /> (atY) (QtY) <br /> Backflow Prevention Device(Inside Building)-select devices below: Shower,Tub,or Combo <br /> Fire Service:❑DCDA, Domestic Service:❑RPBA❑DCVA Commercial Sink(3-compartment,prep,floor) <br /> Clothes Washer Residential Sink(kitchen,bath,bar) <br /> Dishwasher Utility Sink(laundry,mop) <br /> Drinking Fountain Toilet <br /> Floor Drain Urinal <br /> Hose Bibb Wastd/Water Pipe Repalf- L_. <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 Elector 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 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.1 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# <br /> P02 <br /> Owner/Authorized Agent Signature Date (Revised 412112022) <br />