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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@everetlwa.gov I(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET rnq( � ,� �r PARCEL#: <br /> CITY FtxlA STATE f' zip <br /> SUITEMNIT M FLOOR#: ADDITIONAL LOCATION INFORMATION: <br /> TENANT/BUSINESS NAME(if non-residential): <br /> CONTACT INFORMATION <br /> OWNER NAME: <br /> OWNER MAILING ADDRESS: STREET <br /> CITY STATE ZIP <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR COMPANY NAME: md�( P'V <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): FLOP 4- a B Q ITY OF EVERETT BUSINESS LICENSE#(REQUIRED): <br /> CONTRACTOR ADDRESS: STREET r <br /> CITYFd ),*isSTATE Lv ZIP 1 godk <br /> CONTRACTOR PHONE:v'%-A7- CONTRACTOR EMAIL: - g I C` , <br /> PRIMARY CONTACT: ❑OWNER J:�-CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT AME: CONTACT PHONE: a()6.- _ 5q?-7 <br /> 5�lv &_LeCONTACT EMAIL: k Aqc IC.(K 1tiIG1�1 .( Ovq., <br /> PLUMBING PERMIT INFORMATION VALUATION OF WORK:$ 15,0o y O C7 ASSOCIATED PERMIT#(if applicable): p p��t(/O g <br /> '- O5 <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:MSFR ❑Townhouse ❑Duplex ❑ADU ❑Multi-Family-#Units: ❑Commercial 1❑`Accessory Structure <br /> DESCRIPTION OF WORK:�8 0. L L,_ CrN� t lowe/t1ri roo N` r c�w� �� LI�f��� iTJ �C7 t'`�p r <br /> O�.fec D-� �Ut15e <br /> PLUMBING PERMIT FIXTURE COUNT (SCOPE OF WORK) <br /> Fixture Fixture <br /> Count List of Fixtures Count List of Fixtures <br /> (Qty) (Qfy) <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 /> i Clothes Washer Residential Sink(kitchen,bath,bar) <br /> 1 Dishwasher Utility Sink(laundry,mop) <br /> Drinking Fountain Toilet <br /> Floor Drain Urinal <br /> Hose Bibb WasteANater 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 Other(List Type): <br /> ACKNOWLEDGEMENT.,1 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 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 /> L iL o a0 A P #2 Lk <br /> O"l� <br /> Owner/Authorized Agent Signature �- Dale (Revised 412112022) <br />