1417 RUCKER AVE 2025-10-06 - Laserfiche WebLink

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) r� `�/�P,n, YR`�OJECT SITE INFORMATION PROJECT SITE ADDRESS: STREET vl VV--C PARCEL M CITY STATE ZIP SUITEIUNIT M FLOOR#: ADDITIONAL LOCATION INFORMATION: TENANTIBUSINESS NAME(if non-residential): CONTACT INFORMATION NL OWNER NAME:fI(U.(k E✓ Ulf/ OWNER MAILING ADDRESS: STREET CITY '1-7-UA,rtw STATE L,4h ZIP a ZU OWNER PHONE: Li Z<- 4 Z t, OWNER EMAIL, �,(, f� }- CONTRACTOR COMPANY NAME: WA STATE CONTRACTOR LICENSE#(REQUIRED); CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): CONTRACTOR ADDRESS: STREET CITY STATE 21P CONTRACTOR PHONE: CONTRACTOR EMAIL: PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR ❑OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: q7,!5— qt<l L CONTACT EMAIL: f' '.N r PLUMBING PERMIT INFORMATION VALUATION OF WORK:$ UV ASSOCIATED PERMIT#(if applicable): (Valuation shall include the prevailing fair market value ofall 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: PLUMBING PERMIT FIXTURE COUNT (SCOPE OF WORK) Fixture Fixture Count List of Fixtures Count List of Fixtures (Qty) (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 Wastemater Pipe Repair ice MakerI Water Service Line(Behind meter,private side) Grease Interc a Water Valves/Fixtures Sand/Oil Interceptor L LWatereater-Electric Medical Gas eater-Gas Roof Drains List Type): Sewage Eiector Pump/Sump Pump 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 State Contractors Law 18.27 RCW and 286.200A WAC. City of Everett Official Use Only PERMlT# OwnerlA�Agent Signature Date (Revised 4/21/20 2}