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PLUMBING PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> EVERETT SUBMITTAL INSTRUCTIONS: 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 l Y 0n7 C7 f PARCEL M CITY ✓G 7��"77- STATE WA ZIP <br /> SUITE/UNIT#: -*- A L lj L FLOOR M j q Z ADDITIONAL LOCATION INFORMATION: <br /> TENANT/BUSINESS NAME(if non-residential): NIA <br /> CONTACT INFORMATION <br /> OWNER NAME: L,,-),yA11rS (✓ L/Vl <br /> OWNER MAILING ADDRESS: STREET ago <br /> p CITY F'v e re STATE �/A ZIP <br /> OWNER PHONE: yZ - /���`�� OWNER EMAIL: LON A (-d) co wtAz t /-, vi e, <br /> CONTRACTOR COMPANY NAME: <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED): ITY OF EVERETT BUSINESS LICENSE#(REQ ED): <br /> CONTRACTOR ADDRESS: STREET YS 3 Z L It 54, 5 F, �{ p(� <br /> CITY /�v�+�� STATE LUA ZIP I l3 "L) <br /> CONTRACTOR PHONE: 2-10 -7 - 3 Z CONTRACTOR EMAIL: t <br /> PRIMARY CONTACT: OWNER ❑CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: 2 _ -5- 9/ <br /> Lpnrl`t? S ilu�J'Ma�1 <br /> CONTACT EMAIL: LOAN '--) Co—e-4571 nE' <br /> PLUMBING PERMIT INFORMATION <br /> VALUATION OF WORK:$ ASSOCIATED PERMIT#(if applicable): il✓ <br /> (Valuation shall include the prevailing fair market value of all labor,materials,and equipment needed to complete the work,whether actually paid or nol. <br /> BUILDING TYPE: ❑SFR []Townhouse []Duplex ❑ADU AlMulti-Family-#Units:_ ❑Commercial ❑Accessory Structure <br /> DESCRIPTION OF WORK: / <br /> P,gj►Ce y ele46e- (v_,01 1- ACCa`)01`5 a-di t'XPuNS/9r, vtaAky ao-d rTla(e (q�vf- <br /> PlPcoq wl,fbi ptF-X (A�Ireav `I k Mug4ott-� <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 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): rc ►« (a to /tit <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 I am authorized by the owner of this property to perform the work for which application is made, <br /> and I c mply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> r <br /> �?/v PERMIT# f246-1- <br /> 0 <br /> 2 <br /> Owner/Authorized Agent Signature Date (Revised 412112022) <br />