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• <br /> E PLUMBING PERMIT APPLICATJ <br /> EVERETT SUBMITTAL CITY OF EVERETT PERMIT SERVICES <br /> 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 I(E)everetteps@everettwa.gov 1(W)everettwa.gov/permits <br /> (Blue or Black Ink Only Please) PROJECT SITE INFORMATION <br /> PROJECT SITE ADDRESS: STREET 35 l 7 Rc,(pket— Ave PARCEL#: <br /> CITY E vet e`t-E STATE R ZIP K C Zo l <br /> SUITE/UNIT#: FLOOR#: ADDITIONAL LOCATION INFORMATION: <br /> TENANT/BUSINESS NAME(if non-residential): TCMyckki. 4. �N„ ,v s-(-or <br /> CONTACT INFORMATION <br /> OWNER NAME: Byvv,3 i 1 Kist <br /> OWNER MAILING ADDRESS: STREET I°I 2S ( -tint L. S In) Uvc+ F. <br /> CITY E vere+4 STATE (01716r ZIP le Zoti.. <br /> OWNER PHONE: 206 / OWNER EMAIL: Bes4 @N* <br /> cwv4:1 - CoCo % <br /> CONTRACTOR COMPANY NAME: (J "' VUI.%r <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: Q_KN� �1 C DP�N�� CONTACT PHONE: ZD( 8,11 <br /> Z31 S <br /> �l CONTACT EMAIL: beSf Y C�i. (-(o{ [.cow' <br /> PLUMBING PERMIT INFORMATION <br /> VALUATION OF WORK:$ '{-00 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 ❑ADU ❑Multi-Family-#Units: L 'Commercial ❑Accessory Structure <br /> DESCRIPTION OF WORK: rN <br /> ReIocc.-4-n otie—ccfl 4 tet4 Sisk *o Ine) to c(i514 t~ jt., +o GaS-Eat( <br /> 1-.�Jo—�* 61�tk . 1 <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 Z 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): <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 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 comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> PERMIT# _ <br /> Owner/Authorized Agent Signature Date (Revised 2/8/2021) <br /> 1�z <br />