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��`��� / ��W�� ��I�ITY A�������'I�N
<br /> + • CITY 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.gov/permits
<br /> PROJEC'i' SITE lP1FORMATION
<br /> PROJECTADDRESS:n��I �(
<br /> IF APPLICABLE: ❑ OUTSIDE CITY LIMI- S ❑ BUILDING AREA SF ❑ LOT#
<br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? ❑ NO ❑ YES, FROM TO
<br /> UTILITY APPLICATION INFORNIATIOIV
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> ❑ SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION
<br /> ❑ SIDE SEWER ALTERATION ❑ COMPLETE SERVICE ❑ METER ONLY
<br /> ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE:
<br /> �INSTALL BACKWATER VALVE(outside the building) ❑ SFR
<br /> ❑ SIDE SEWER CAP-OFF ❑ MULTI-FAMILY-#OF UNITS:
<br /> ❑ SIDE SEWER RECONNECTION ❑ COMMERCIAL
<br /> MUI_TIPL.E DOAAF_ST1C 1!1/ATER S�R�/ICES REC�UEST WATFR SERVICE TYPE/S17E (circle desired size)
<br /> ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR ❑ DOMESTIC: 3/4", 1", 2", OTHER:
<br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ �RRIGATION: 3/4", 1", 2", OTHER:
<br /> ❑ I AM OPTING TO �NSTALL MULTIPLE DOMESTIC WATER ❑ FIRE: 1", 2", 4", 6", 8", OTHER:
<br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER ❑ DOMESTIC/FIRE COMBO: 1", 2", OTHER:
<br /> SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM.
<br /> CONTACT INFORMATION
<br /> OWNER NAME: TENANT NAME(lf Commercial):
<br /> OWNER MAILING ADDRESS: srReer
<br /> CITY STATE ZIP
<br /> OWNER PHONE: OWNER EMAIL:
<br /> _....._.�._.... .._.....__ _,_... _. .._ ,.. _... _ - ,. . ......._.:...... ... .. ._ . - -
<br /> _. ... . ........ .. . ,_.._ ...._. _...... ......... ..,........._ ,._.._ ._..,_.:��. ..,.
<br /> CONTRACTOR NAME. �'�� � d j '� ,'� "� � ��� '
<br /> .t 1� , ��
<br /> CONTRACTOR ADDRESS: sTReeT ?,;� `A � � ' ,'o� ✓� �` � ''��
<br /> CITY '�� , N.�/ � ' STATE �;'�f �`� ZIP ��r�Zf/�
<br /> CONTRACTOR PHONE `���'j ��I/)��`j� �� CONT CTOR EMAIL �'' ;�;' ��`,,,f�'� !�"� ``''�� ��° ��� �`)�� �'(,�s�%, t�,
<br /> CONTRACTOR LIC.#(RECIUIRED): �g ����f� �� �{ � � � CITY OF EVE ETT BUSINESSeLIC.#(REQUIRED): � I L�jl�� `
<br /> PRIMARY CONTACT: ❑OWNER ❑ CONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: �'�;q,"�� � �a��� �
<br /> ��'�����' �E��' � I�� ��7 �L CONTACT EMAIL� /"" �� 'I �/����� I' �� ��" � �C� ������G' '�"1.(r���� � r� �� ��
<br /> AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title City of Eve�ett 0 �cial Use Only
<br /> 14 Water and Sewer o�such ofher rules and regulations now existing or which may be esfablished from time to FEE
<br /> time. The applicant fu�ther agrees, as a condition precedenf fo�eceiving service that the utrlities division shall have �
<br /> the�ight at any fime, without notice,to shut off or turn on the water supply for repairs, construction,and �'����� �
<br /> nonpaymenf of charges or for any ofher reasonab/e cause.I am the owner, or I am authorized by the owner of this
<br /> property to perform the wo�k for which application is made, aru�l comply with fhe State Conf�actors Law 98.27 PERMIT#
<br /> RCW�nd 296.20�A WAC. '� ` ,� ^� , (� /�
<br /> ei`� rfM 8,� �e �j"�� X��1' f�� ����� >� }'' � , � I ' � �� U�.— j� i L�I
<br /> !�� �� U I
<br /> Owner/Authorized Agent Signature Date (Revised 10/12/2095)
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