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PLUMBING PERMIT APPLICATION EVERETT SUBMITTAL INSTRUCTIONS: OF EVERETT PERMIT SERVICES S: Drop off hard copy completed paper application to 3200 Cedar Street 2nd Floor Intake Drop Box. WASHINGTON CONTACT INFORMATION: (P)425-257-8810 1(E)PermitServices@everettwa.gov I(W)everettwa.gov/permits (Blue or Black Ink Only Please) PROJECT SITE INFOR ATION PROJECT SITE ADDRESS: STREET U P,0l720 �\ PARCEL#: My ZV e y , STATE �J ZIP jS LC.J 1 SUITEIUNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION: TENANT/BUSINESS NAME(if non-residential): CONTACT INFORMATION OWNER NAME: Dav Q OWNER MAILING ADDRESS: STREET Ve,(SUY"*\ I✓ V CITY STATE L /'- ZIP [ l OWNER PHONE: 7 S L32_ 3 OWNER EMAIL: O Vkl cU 1 Cole CONTRACTOR COMPANY NAME: vj WA STATE CONTRACTOR LICENSE#(REQUIRED): CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): CONTRACTOR ADDRESS: STREET CITY STATE ZIP CONTRACTOR PHONE: CONTRACTOR EMAIL: PRIMARY CONTACT: 9OWNER ❑CONTRACTOR ❑OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: CONTACT EMAIL: PLUMBING PERMIT INFORMATION VALUATION OF WORK:$ V ASSOCIATED PERMIT#(if applicable): (Valuation shall include the prevailing fair market value of all labor,materials,and equipment needed to complete the work,whether actually paid or not.) BUILDING TYPE: ❑SFR ❑Townhouse ❑Duplex ❑ADU ❑Multi-Family-#Units: ❑Commercial ❑Accessory Structure DESCRIPTION OF WORK: 11,1A1 Q Lm16-,,) - ^' o,14 PLUMBING PERMIT FIXTURE COUNT (SCOPE OF WORK) Fixture Fixture Count List of Fixtures Count List of Fixtures Ply) (Qty) Backflow Prevention Device(Inside Building)-select devices below: Shower,Tub,or Combo Fire Service:❑DCDA, Domestic Service:❑RPBA❑DCVA Commercial Sink(3-compartment,prep,floor) Clothes Washer Residential Sink(kitchen,bath,bar) Dishwasher Utility Sink(laundry,mop) Drinking Fountain Toilet Floor Drain Urinal Hose Bibb Waste/Water Pipe Repair Ice Maker Water Service Line(Behind meter,private side) Grease Interceptor Water Valves/Fixtures Sand/Oil Interceptor ater Heater-Electric Medical Gas Water Heater-Gas Roof Drains Sewage Ejector Pump/Sump Pump Other(List Type): 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 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 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, and I comply with the Stale Contractors Law 18.27 RCW and 296.200A WAC. City of Everett Official Use Only Own Authodzed Agent Signature Date (ROWS6v wz ilzuz2)