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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) PROJECT SITE INFORMATION Q <br /> PROJECT SITE ADDRESS: STREET 6107 5AS-1 PARCEL#: 60 S 'OOOOO 80 2- <br /> CITY EvaaETSTATE ZIP <br /> IQ <br /> SUITEIUNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION: <br /> TENANT/BUSINESS NAME(if non-residential): <br /> CONTACT INFORMATION <br /> OWNER NAME: 134T11ZK.-TKuSZGE jJ4416r� g W 79S1417M1,r 1 4A 712L/SN � <br /> OWNER MAILING ADDRESS: STREET PD _910)( 66 <br /> CRY `J ILC 6 ( STATE tVA ZIP /e2dI( <br /> OWNER PHONE: Z`,j 331D 6 OWNER EMAIL: r8(Z klr'k (T hve,CU <br /> CONTRACTOR COMPANY NAME: GQ\C,( CL . tC. LA4 Q (� <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): (,I'PIE`770C?—, IICITY OF EVERETT BUSINESS LICENSE#(REQUIRED): <br /> CONTRACTOR ADDRESS: STREET 2 l- / - rtEi 5-1 N11fi <br /> CITY Z�/J n/(,,7"UJJ STATEW ZIP <br /> CONTRACTOR PHONE: �1 Z3 76fo 3 1CONTRACTOR EMAIL: L e5mpt.coK <br /> PRIMARY CONTACT: X OWNER ❑CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: VZs ��� <br /> CONTACT EMAIL: r-b I r fill ut,Go►A <br /> PLUMBING PERMIT INFORMATION <br /> VALUATION OF WORK:$ _ ASSOCIATED PERMIT#(if applicable): <br /> (Valuation shall include the prevailing fair market value of all labor,materials,and equipment needed to complete the work,whether actualy paid or not.) <br /> BUILDING TYPE: SFR ❑Townhouse ❑Duplex. 1 ❑ADU ❑Multi-Family-#Units: ❑Commercial ❑Accessory Structure <br /> DESCRIPTION OF WORK: 9,�-A CJ[ FJ(1<,VlJCj PL"MBINC� PJPRR ,D2AIMS W&$I S,IWn{ /)Fw 1WHIL'e- <br /> W AU;I AWE- UP09E DNo ADuiT1v F W-�ARE,LUt 06 ADOPrO XCGPr jANKC,rzSS kIOTWhZ <br /> PLUMBING PERMIT FIXTURE COUNT (SCOPE OF WORK) Z Hds(f ) <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 C 1 T/ <br /> Fire Service:❑DCDA, Domestic Service:❑RPBA❑DCVA Commercial Sink(3-compartment,prep,floor) <br /> Clothes Washer Residential Sink i the ,(6at bar) PLAG X LS <br /> Dishwasher Utility Sink(laundry,mop) <br /> Drinking Fountain Toilet R rr P(.AG J()SICIN <br /> Floor Drain Urinal <br /> Hose Bibb Waste/water 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 �(r ,S 7 lit'T <br /> Medical Gas Water Heater-Gas <br /> Roof Drains Other(List Type): <br /> Sevmge Ejector Pump/Sump Pump 10ther(List Type): <br /> ACKNOWLEDGEMENT.•l 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 l am authorized by the owner of this property to perform the work for which application is made, <br /> and l comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> I PERMIT# ✓ <br /> � Z <br /> Owner/Au orized Agent Signature Date (Revised 412112022) <br />