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<br />C1TY OF EVERETT PERMIT SERVICES
<br />3200 CEDAR STREET, EVERETT, WA 98201
<br />(P) 425-257-8810 � FAX �25-257-8857 �(E) everetteps@everettwa.go� � www.everettwa.govlpermits
<br />PROJECT ADDRESS:
<br />IF APPLICABLE:
<br />BUILDING 7"YPE:
<br />CHANGE �F USE?
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<br />❑ OUTSIDE CITY LIMITS ❑ BUILDING ARFA SF ❑ LOT #
<br />DSFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-# OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br />❑ NO ❑ YES, FROM 70 _
<br />: u-���o�r ����.o��-rv�� ar��o���-�uo�
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<br />SEWER (check all that apply) WATER (check all that apply)
<br />❑ SIDE SEWER REPAIR
<br />❑ SIDE SGWER ALTERATION
<br />❑ NEW SIDE SEWER INSTALLATION
<br />� INSTALL BACKWATER VALVE (outside fhe building)
<br />❑ SIDE SEWER CAP-OFF
<br />❑ SIDE SEWER RECONNFCTION
<br />MULTIPLE DOMESTIC WATER SERVICES REQUEST
<br />❑ I AM DECLIN]NG MULTIPLE DOMESTIC WATER SERVICES FOR
<br />MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP
<br />❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER
<br />SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER
<br />SINGLE OWNERSHIP. FILL DUT REVERSE SIDE OF THIS FORM.
<br />OWNER NAME: �
<br />IOWNER MAlL1NG ADDRESS: srREer
<br />CIiY
<br />�WNER PHONE:
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<br />CONTRACTOR NAME: � �� �� �j
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<br />CONTRACTORADDRESS: srREEr �
<br />❑ NEW WATER SERVICE INSTALLATION
<br />❑ COMPLETE SERVICE ❑ METER ONLY
<br />SERVICE / NIETER USE:
<br />❑ SFR
<br />❑ MULTI-FAMILY-# OF UNITS:
<br />CJ COMMERCIAL
<br />WATER SERVICE TYPE I SIZE: (circle desired size)
<br />❑ DOMESTIC: 3/4", �", 2", OTHER:
<br />❑ IRRIGATION: 3/4", 1", 2", OTHER:
<br />❑ FIRE: 1", 2", 4", 6", 8", OTHER:
<br />❑ DOMESTIC/FIRE COMBO: 1", 2", OTHER:
<br />_ ... .. . :,, _ :
<br />CONTACT INFORM_.ATION : .
<br />TENANT NAME Qf Commercial)_
<br />� OWNER EMAIL:
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<br />STATE �P
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<br />CITY � VrC V�UI �{�� STATE ZJP
<br />CONTRACTOR PHONE: G Z ��—b l2 � CONTRAG'TOR EMAIL: t U��� �
<br />CONTRACTOR LIC. #(REQUIRED): ti vI d I� �� CITY OF EVERETT BU5INESS L1C. #(REQUIRED)
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<br />PRIMARY CON7AGT: ❑ OWNER [� ONTRACTOR ❑ OTHER (Please Specify)
<br />CONTACT NAME: CONTACT PHONE; �Z S� ����— (J l 2�j
<br />V I��, C'�' (���� .- CONTACT EMAIL;
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<br />AGREEMENT.� The undersigned applicant agrees to comply wifh all provisions of the Everett Municipal Code "iitle City of F_veretf Offrcial Use Only
<br />94 Water and Sewer or such other rules and regulafions now existing or wf�ich may be established from time to FC�
<br />time_ The applicanf further agrees, as a condifion precedent fo rer,eiving service that the uiilities division shall have �/) fy /"�
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<br />the right at a � e, withouf notice, to shut otf or furn on the wafersupply for repairs, consfruction, and ��� ,�
<br />nonpayme of cha s or for otherreasonable cause. I am the owner, or I am aufhorized Gy the owner of this
<br />properfy t perf m� wor'k for w'ch application is made, and I comply with the Sfate Confracfors Law 9t3.21 pERMIT �� /�
<br />RCWan 29 200 C. �� �,�J� q N I I n� r�,� DI (/I
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<br />Dafe (Revised 90/12/2095) — -
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