Laserfiche WebLink
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 <br /> PROJECT SITE ADDRESS: STREET � V PARCEL#: <br /> V V CITY " STATE k/ ZIP <br /> SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION: <br /> TENANT/BUSINESS NAME(if non-residential): <br /> CONTACT INFORMATION <br /> OWNER NAME: Lie(le=dL 1.2107h <br /> OWNER MAILING ADDRESS: STREET V <br /> CITY �V�V(O STATE e,' 'A ZIP 8Z <br /> OWNER PHONE: �,�5 — 1 OWNER EMAIL: <br /> CONTRACTOR COMPANY NAME: ©edh <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: OWNER ❑CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: ( CONTACT PHONE: <br /> fr✓{n� (fcz v, CONTACT EMAIL: c­t—_ cp l7C---.) <br /> PLUMBING PERMIT INFORMATION <br /> VALUATION OF WORK:$ ASSOCIATED PERMIT#(if applicable): Q <br /> (Valuation shall include the prevailing fair qarket value of all labor,materials,and equipment needed to complete the work,whether actually paid or not.) <br /> BUILDING TYPE: ❑SFR ❑Townhouse Kuplex ❑ADU ❑Multi-Family-#Units: ❑Commercial ❑Accessory Structure <br /> DESCRIPTION OF WORK: <br /> et 1 f JD(A&01 tks �Qu.�,,� L>w,, <br /> PLUMBING PERMIT FIXTURE COUNT (SCOPE OF WORK) <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 <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 WastefWater 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 P Or <br /> Medical Gas Water Heater-Gas <br /> Roof Drains Other(List Type): <br /> Sewage Ejector 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 ore 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 /> City of Everett Official Use Only <br /> PERMIT fl /) y�� _ N <br /> U <br /> Owner/Aut orize g gignal&.r. '� D t (Revised 412112022) <br />