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<br /> C1TY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT',WA 98201
<br /> (P)425-257-8810 ( FAX 425-257-8857 � (E) everetteps@everettwa.gov � www.everettwa_gou/permits
<br /> �� � ,��� �����{. ���� °�����G�T��SI�' ',E�IINFORMATIO�N� � '�```,������,` *�������,�_ .��
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<br /> PROJECT ADDRESS: �O i S" -'. �i �+ � �
<br /> IF APPLICABLE: ❑OUTSIQE C1TY LIMITS ❑ BUILDING AREA SF ❑LOT#
<br /> BUILDING TYPE: ❑SFR DETACHED ❑SFR ATTACHED ❑DULEX.�IULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRiAL
<br /> CHANGE OF USE? ❑NO ❑YES, FROM TO
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<br /> `����h`�"�� °° ; .:. ,.Y UTILITY APPLICATION�,INFORMATION , ..,������£��.;�;��"�' ;S�s�
<br /> s���.F.�.�� ' _ ._:�«� ..__. _, .. �`n�. �:,..
<br /> � SEWER(check all thafi apply) WATER(check all fhat appiy)
<br /> ❑SIDE SEWER REPAIR ❑NEW WATER SERVICE INSTALLATION
<br /> SIDE SEWER ALTERATION ❑COMPLETE SERViCE ❑METER ONLY �
<br /> ❑ NEW SIDE SEWER WSTALLATION SERVICE/METER USE:
<br /> ❑ INSTALL BACKWATER VALVE outside the building) ❑SFR
<br /> ❑ SIDE SEWER CAP-OFF ❑MULTI-FAMILY-#OF llNITS:
<br /> ❑SIDE SEWER RECONNECTION ❑COMMERCIAL
<br /> MULTIPLE DOMESTIC WA?ER SERVICES REQUEST WATER SERVtCE TYPE/S1ZE: (circle desired size)
<br /> ❑ I AM DECUNING MUL7IPLE DOMESTIC WATER SERVICES FOR ❑DOMEST(C: 3/4", 1", 2", OTHER.
<br /> MY MULTI-FAMlLY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑IRRIGATION: 3/4", 9", 2", OTHER:
<br /> ❑�i AM QPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑FIRE: 1", 2", 4", 6", 8", OTHER:
<br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER ❑ DOMESTIC/FlRE COMBO: 1", 2", OTHER:
<br /> SINGLE OWNERSH(P. FlLL DUT REVERSE S/DE OF THIS FORNI.
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<br /> ° CONTACT IN RMATION � :
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<br /> OWNER NAME• 5' � TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: srn�r � '—�
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<br /> C1TY STATE Cil//� ZIP ��`�
<br /> OWNER PHONE: � =7�— Q OWNER EMAIL: _
<br /> CONTRACTOR NAME: 5 '�
<br /> CONTRAC7'OR ADDRESS: _sTReer �{ S?�'�7� 1.�
<br /> CiTY � . STATE ZIP / � �
<br /> CONTRACTOR PHONE: Q —[p — r �� GONTRACTaR EMA[l.:
<br /> CONTRACTOR LIC.#(REQUIRED)•�ST�� �7�J�.-D- C(TY OF EVERETT BUSINESS L1C.#jREQU1RED): OS��
<br /> PRIMARY CONTACT: ❑OWNER `�CONTRACTOR ❑OTHER(Please Specifiy) �
<br /> CONTACT NAME: CONTACT PHONE: ��-- �.—��p��p
<br /> .►o.-rf iC ��'C�� CONTACT EMAIL: ���� � � (�� � C�f jl/�
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<br /> AGREEMENT.'The undersigned applicanf agrees to comply wifh all provisions of tfle Everett Municipa!Code Title City of Everett Official Use Only
<br /> 94 l�Uater and Sewer or such other rules and regulations now existing or which may be esfablished from fime to FEE ��
<br /> fime.The applicant further agrees, as a condition precedent to receiving service fhat the utilities division shal!have .�
<br /> the right at any time,without notice,to shut off or fum on the water supply for repairs,construction,and
<br /> nonpayment of charges or for any otherreasonable cause./am the owner,or I am aufhorized by the owner of this
<br /> property t erform the work for which application is made,and 1 comply with fhe State Contractors Law 18.27 PERMIT#
<br /> n .200A WAC. � ��� r Q
<br /> Owner/Au horized Agent Signature Date (Revised 90/92/2095J
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