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WdtER I SEWER UTILITY LICATION
<br /> �/ CITY OF EVERETT PERMIT SERVICES
<br /> ��� iv
<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 SITE INFORMATION
<br /> PROJECT ADDRESS: 72 S 1/z51- 56 – V.441-1 4, 16, le C-
<br /> IF
<br /> IF APPLICABLE: -B-6iii-SIDE CITY LIMITS ErstfttDThG AREA SF 0 LOT#
<br /> BUILDING TYPE: ASFR-DETACHED ❑SF42=A�TACHED ❑DtfL-PX ❑Mt T-I-FAMI-L�`4OF UN+TS: ❑COMMERCIAL DINDUSTRIAL
<br /> CHANGE OF USE? 0 NO ❑YES, FROM TO
<br /> UTILITY APPLICATION INFORMATION
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> ❑FSlDE SEWER REPAIR U,-NEW /VATER SERVICE INSTALLATION
<br /> EI-SIDE SEWER ALTERATION -❑ COMPLETE SERVICE 0 METER ONLY
<br /> B NEW SIDE SEWER INSTALLATION SERVICE/METER USE:
<br /> CM-STALL BACKWATER VALVE(outside the building) 0-8FR
<br /> ]SIDE SEWER CAP-OFF El-MULTI-FAMILY-#OF UNITS:
<br /> .E1 SIDE-CEWER RECONNECTION 0 COMMERCIAL
<br /> MULTIPLE DOMESTIC WATER SERVICES REQUEST • WATER SERVICE TYPE/SIZE: (circle desired size)
<br /> -EF-1=AM-3i=CL!NING MULTIPLE DOMESTIC WATER SERVICES FOR ❑-DOMESTIC: 3/4", 1", 2", OTHER:
<br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. fl tRRIGATION: 3/4", 1", 2", OTHER:
<br /> -I:FtAWING TO INSTALL MULTIPLE DOMESTIC WATER 0 FIRE: 1", 2", 4", 6", 8", OTHER:
<br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER atrOMESTIC/FIRE COMBO: 1", 2", OTHER:
<br /> SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM.
<br /> CONTACT INFORMATION
<br /> OWNER NAME: /'I II l iihMo 1111 2 Iidt nL4ITENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET ///4Z Cr /i 4'��j / q e (a V / lam,/ 2
<br /> CITY (�(��it�l�/r�°W7f -� I STATE tui/b 1 ZIP /(,1©.77
<br /> 7 2-Z— .../:7 !/ OWNER EMAIL. eq/J�/�s,,'1 AV6/t4 S/tOhO/ 1.,S6 lei,
<br /> OWNER PHONE: /4"9.-� / ,._ .-...,, . ....,..-......,.M
<br /> CONTRACTOR NAME: SA-046 AS OUM g-
<br /> CONTRACTOR ADDRESS: S REST
<br /> CIN STATE ZIP
<br /> CONTRACTOR PHONE:
<br /> _. ..,_.._..._. .,...__ ...,.....,,.�,..,_Y,..,:,...CONTRACTOR EMAIL:CONTRACTOR LIC #(REQUIRED): � f .72.- Dl- CITY OF EVERETT BUSINESS LIC.#(REQUIRED)T Pr73-0....----
<br /> PRIMARY CONTACT: OWNER 0 CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: A �� CONTACT PHONE: (4z) 922– •24:4
<br /> /
<br /> £YI4 f7< --zs CONTACT EMAIL: (Writhy zy)&f/ j o ip':)0`Jo'n 4SA tea,
<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 may be established from time to FEE 0°
<br /> time. The applicant further agrees, as a condition precedent to receiving service that the utilities division shall have
<br /> the right at anytime,without notic to shut off or turn on the water supply for repairs,construction,and D --
<br /> nonpayment of c - ::.. . for oo herreas able cause.I am the owner,ori am authorized by the owner of this _
<br /> property to•-rfor the w•rk Ty
<br /> applic tion is made,and I comply with the State Contractors Law 18.27 PERMIT#
<br /> RCW a .296. SOA W°C. I� �
<br /> G' v L U ,e�/„_ ©O I
<br /> � CJI./
<br /> Own- •uthorized Age " nati re Bat- (Revised 10/12/2015)
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