Laserfiche WebLink
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 �U"t �/ Q�-�— _AVNO— PARCEL#:CITY , STATE W J 'n� <br /> ZIP <br /> SUITEIUNIT#: (5 k FLOOR M 1 ADDITIONAL LOCATION INFORMATION: <br /> TENANTIBUSINESS NAME(if non-residential): 0(j Jj LL.� <br /> CONTACT INFORMATION <br /> OWNER NAME: <br /> OWNER MAILING ADDRESS: STREET `0\UL \-J J� <br /> CITY IC �1\) i \ T\ STATE\,/A ZIP CA z(A <br /> OWNER PHONE: q 7'C2 LA I C'\l OWNER EMAIL: PTV\4 <br /> /� I <br /> CONTRACTOR COMPANY NAME: F 1U,✓ Lo,-A o \vw\�i L�—C, <br /> WA STATE CONTRACTOR LICENSE#(REQUIRED):F i(�ti/C(�Q L�Un� CITY OF EVERETT BUSINESS LICENSE#(REQUIRED): Ij-77 <br /> CONTRACTOR ADDRESS: STREET 0 (5 CITY 1�-�l/`\� 5��� J STATE W/y4� \ ZIP �S <br /> CONTRACTOR PHONE: _12.$-S Z-CAt-i"�5 CONTRACTOR EMAIL: <br /> PRIMARY CONTACT: ❑OWNER CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: <br /> Ro � CONTACT EMAIL: 1(J��/Cc:+�� >` l^i`� CU•�Cr��� <br /> PLUMBING PERMIT INFORMATION <br /> VALUATION OF WORK:$ U UU 1ASSOCIATED PERMIT#(if applicable): <br /> (Valuation shall Include the prevaUing 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: Wommercial ❑Accessory Structure <br /> DESCRIPTION OF WORK: <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): <br /> Sewage Ejector Pump/Sump Pump I 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 l am authorized by the owner of this property to perform the work for which application is made, <br /> and l comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> PERMIT# (Ip�0 �I <br /> OwneriAuthorized Agent Signature Date (Revised 412112022) <br />