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,011 .1111P-vi-_ Wt W ER I SCS'\i\IER UTILITY i PUCAT O <br /> ' _, CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> (P)425-257-8810 I FAX 425-257-8857 I (E) everetteps@everettwa.gov I www.everettwa.gov/permits <br /> PROJECT S TE INFORMATION <br /> PROJECT ADDRESS: 3K \c-2._Z Cs� S P i,Jr / //� <br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA �Ga l. SF 0 LOT# 4 ; <br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ESIDULEX DMULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL <br /> CHANGE OF USE? 0 NO 0 YES, FROM TO <br /> UTILITY APPLICATION INFORMATION <br /> SEWER(check all that apply) WATER(check all that apply) <br /> O SIDE SEWER REPAIR KNEW WATER SERVICE INSTALLATION <br /> 44:SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY <br /> O NEW SIDE SEWER INSTALLATION SERVICE/METER USE: <br /> O INSTALL BACKWATER VALVE(outside the building) 0 SFR <br /> O SIDE SEWER CAP-OFF 0 MULTI-FAMILY-#OF UNITS: <br /> 8 SIDE SEWER RECONNECTION . 0 COMMERCIAL <br /> MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE: (circle desired size) <br /> O IAM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR K DOMESTIC: 3/4 1", 2", OTHER: <br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. 0 IRRIGATION: 3/4", 1", 2", OTHER: <br /> KI AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑ FIRE: 1", 2", 4", 6", 8", OTHER: <br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER 0 DOMESTIC/FIRE COMBO: 1", 2", OTHER: <br /> SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. <br /> CONTACT INFORMATION _ <br /> OWNER NAME:00/V S --QZ.._ / ,,TENANT NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET 36/5 I ��NVV <br /> a L d c Ct STATE SVT ZIP ? <br /> .. ..Y..)-6S-2--\e7 <br /> �� CITY 1 (� n <br /> OWNER PHONE: . ..X)-6S-2'\l'j as— OWNER EMAIL: q� �O rU ® rtck c-c_, <br /> (11 <br /> CONTRACTOR NAME: /\ (2 /Cf-ee_V ` CO Se(-8'W 7 <br /> CONTRACTOR ADDRESS: STREET 3L( . l'n ��(or <br /> CITY h/(.UJ6 J STATE ` ZIP 9,3-s(? <br /> ? <br /> CONTRACTOR PHONE: 2S-3'30-1,�23 CONTRACTOR EMAIL: <br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED) -._ ,,, — <br /> PRIMARY CONTACT: KOWNER 0 CONTRACTOR 0 OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: 62_87---V56 --(Sc Z 3 <br /> CONTACT EMAIL: L„CO('' 1 <br /> AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title City of Everett Official Use Only <br /> 14 Water and Sewer or such other rules and regulations now existing or which maybe established from time to FE <br /> time. The applicant further agrees, as a condition precedent to receiving service that the utilities division shall have O <br /> the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and <br /> nonp.yme of charges or for any other reasonable cause.I am the owner,or!am authorized by the owner of this <br /> props y to p= orm the work for wh'h application is made,and I comply with the Statt-te Contractors Law 18.27 PERMIT# <br /> RCW: d296.•OOAW� � U k� ( � 02 <br /> Owner/Authorized Agent Signature ate (/ //_(/ (Revised 10/12/2015) <br /> I� <br />