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<br /> � ���� / ����� ��I�I�� 1����'�� I�O��
<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 /> PROJECT SITE IPIFORM�►TIOPI
<br /> PROJECT ADDRESS: �' /� � ���
<br /> �
<br /> IF APPLICABLE: ❑ OUTSIDE CITY LI ITS ❑ 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 INFORMATION
<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 RECONNECTfON ❑ COMMERCIAL
<br /> IuIUITIPLE DOMESTlC 1/11AT�R SER\/ICES REC?UEST WATER SERVICF TYPF/S17F� (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 INSTALL 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 TNIS FORM.
<br /> CONTACT INFORMATION
<br /> OWNER NAME: TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: sTRee-r
<br /> CITY STATE ZIP
<br /> OWNER PHONE: OWNER EMAIL:
<br /> _.,... _ ._.._,. .,,_. ___ __.__. .... ....._ . . .....,._ �_,,..._.. .��..__. . ......_....
<br /> _.._ _... _,.._ ....�. ___...,. ._. _.._ . __._ _....,,,., .._.... . ..__..._. ._ .,., .,. .._.:_,_...._..,.
<br /> CONTRACTOR NAME: • �' �� � 'j ��� ,� � '
<br /> . ,..
<br /> CONTRACTOR ADDRESS: sTReeT �j� t � `� � °�y-����/�1'�, �<� '�°''�"'
<br /> �A g�' ��
<br /> CITY �` .`/� � � STATE ;�f ZIP � ?��
<br /> CONTRACTOR PHONE `�� ����G ��'�j CONT CTOR EMAIL:��,���` ,i �`�, !d�;R"'� ��°.��� J ���(1 ��.'�m'�,'' �%
<br /> CONTRACTOR LIC.#(REQUIRED); � �� �� �°� � � � C1TY OF EVE�ETT BUSINESS L1C.#(REQUIRED): �'� �G-,��
<br /> PRIMARY CONTACT; ❑OWNER ❑ CONTRACTOR ❑ OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: � �'�,,� u ?�� G
<br /> ��.�o�'�`�L-� ���,�,� I ��i� � CONTACT EMAIL:�' ;� a1 �I�� �' �/ I � �����'� � �`�'�d� � � � ����'I�
<br /> AGREEMENT:The undersigned applicanf agrees to comply with all provisions of the Everett Municipal Code Tifle �- City of Everett rcia!Use Only
<br /> 94 Water and Sewer o�such ofher rules and regulafions now existing or which may be esfablished f�om time to FEE
<br /> time. The applicant further agrees,as a condition precedent to receiving service fhat the utilrties division shall have ,� v��
<br /> the right at any time,without notice, to shut off or turn on the water supply fo�repairs,consfruction, and • �.�f ) �
<br /> nonpaymenf of charges or for any other reasonable cause. I am the owner,or I am authorized by the owner of this �
<br /> property to perform the work for which applicafion is made, and l comply with the State Contractors Law 18.27 PERMIT#
<br /> RCW�nd 296.20 A WAC. ` ' ,;,
<br /> I�i9,�.,"'�'t� � ���'�`�.�,i�'°v�'��'��0 � �'I,� � �� � I (e�������
<br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015)
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