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ATER I �� � ��'I�I�Y ��P�BC�`�IOi�
<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'T S17'E IidFORMAT10�1
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<br /> PROJECT ADDRESS: � —
<br /> IF APPLICABLE: ❑OUTSIDE CITY LIMITS ❑ 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 INFOItMAT10Id
<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 /> MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE: (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. ❑ IRRIGATION: 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. F/Lt OUT REVERSE SIDE OF THlS FORM.
<br /> CONTACT INFORMATION
<br /> OWNER NAME: ` `"r� � � C� .� TENANT NAME(If Commercial):
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<br /> OWNER MAILWG ADDRESS: sTReET Z 2 — r� �Ce�7G� �-G-�.��
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<br /> In•� (/`-" � � STATE ZIP C�/ /
<br /> OWNER PHONE: 2V� - �L��- �7 S�� OWNER EMAIL: �� �� ✓2'��L�7
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<br /> CONTRACTOR NAME: � �� �' � �U" �`���'? l`�� " � �/2���� �
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<br /> CONTRACTOR ADDRESS: sTRee-r / � „J/ � r `5 � C�
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<br /> CONTRACTOR PHONE: `�Z ) � Z 5✓'�' �Z��Z CONTRACTOR EMAIL: 1"�G���L C ��/����� �� �L'��F' �
<br /> CONTRACTOR LIC.#(REQUIRED): i`� ��/ ��'� '� �� �� CITY OF EVERETT BUSWESS LIC #(REc2UIRED)
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<br /> PRIMARY CONTACT: ❑OWNER CONTRACTOR ❑ OTHER(Please 5pecify)
<br /> CONTACT NAME: CONTACT PHONE: �Z � � �Z G�' -- �?j �-�i
<br /> �J/ic.-�'/C- �L'����I/�r C� CONTACT EIViAIL: ,�C'�.vC C ��'/ .�v��C�/`�f,�' � tV f'.
<br /> AGREEMENT:The undersigned applicant agrees to compl ith all provisions of the Everetf Municipal Code Tifle City of Everetf Offici 1 Use Only
<br /> 94 Wafer and Sewer or such other rules and regulafions now existing or which may be established from time to FEE
<br /> time. The applicant fu�ther agrees, as a condition precedent to receiving service that the utilities division shall have � �i Q�
<br /> fhe right af any time,without notice,to shut off o urn on the water supply for repairs,construction,and ,,.�
<br /> nonpayment of charges or for any other reas able cause.I am the owner,or I am aufhorized by the owner of this
<br /> property to perfo�m the work f ap cation is mad comply with the State Contracfors Law 18.27 PERMIT#
<br /> RCW and 29G200A WAC.�_J- � ,� �' f � '� ' ���/�
<br /> G / (/I
<br /> Owner/Authorized Agent Signature Date (Revised 10/92/2095)
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