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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 lfik'OnlyPlease) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET G �//-3 r— V — PARCEL#:, 7 <br /> cn-Y �V CA e.+�•{- STATE W/i ZIP zo / <br /> SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION: <br /> TENANT/BUSINESS NAME(if non-residential): G C�S Q 01,1(U5 ZLLVy t Q , ,C 6Lt-, - 5 +0"V C' ,� <br /> CONTACT INFORMATION <br /> 6WNER�IAME:�O Q• a c�. C.V)Gt- <br /> OWNER MAILING ADDRESS: STREET- � d fit` 1�14o(/) <br /> /crry ary/ (J It I e STATE W,4- ZIP <br /> OWNER PHONE: y 2 S �r�l s• OWNER EMAIL:c 6- y\Gt \c4,(lQ Peg �?-7-4 /�6Lo U a CI aq <br /> CONTRACTOR COMPANY NAME: „(�(.J/ '� (�(,J �`(,(� Aff 1. �'EZ G 1 Cloud , C oV4 <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): K' J CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): <br /> CONTRACTOR ADDRESS: STREET <br /> Cm STATE zIP <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR ❑OTHER(Please Specify) '1iO—N A t-+T- <br /> CONTACT NAME: CONTACT PHONE: <br /> CONTACT EMAIL: <br /> PLUMBING.PERMIT.INFORMATION <br /> VALUATION OF WORK:$ 6 O 0 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 actually paid or not.) <br /> BUILDING TYPE: ❑SFR ❑Townhouse ❑Duplex ❑ADLI ❑Multi-Family-#Units: ❑Commercial ❑Accessory Structure <br /> DESCRIPTION OF WORK, Q GL1� r 1 � t ..f ke, \ Q(d ► 10 S i to &- Gad 2 CO MPartAl, <br /> ( �Gi t;,l�l� rc tv.$ }mot(; .� (� tle�sJ 60(' S j� Lam, (,U t 4 `^ {�1�e d '- S r,�,�i L✓� w✓� <br /> PLUMBING PERMIT FIXTURE COUNT (SCOPE OF W ) ; <br /> Fixture Fixture DEC O I <br /> 20 lJ r <br /> Count List of Fixtures _ count List of Fixtures U f <br /> (QtY) (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-compartme t; e r a t <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 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 <br /> Medical Gas Water Heater-Gas <br /> Roof Drains Other(List Type): <br /> Sewage Ejector Pump/Sump Pump I I 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.f am the owner,or 1 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 /> V L� Cee-, Cd 2 �/ � Z�e 2 0^0 S <br /> Owner/Authorized Agent Signature Date ( (Revised 412112022) <br />