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�Q�� s �� J�O�� Q��'��i �� CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P)425-257-8810 � FAX 425-257-8857 � (E) everetteps@euerettwa.gov � www.everettwa.gov/permits P�iO.J��`�' SI�'� 94��Rtlli��'9�R! PROJECT ADDRESS: ;� �� V� ^✓��-�'� � IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? ❑NO ❑YES, FROM TO ��ri�t-rlr ��'c��°vor� a�Fo�m�,�r0o� SEWER(check all that apply) WATER(check all that apply) �.�SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALIATION ❑ SIDE SEWERALTERATION ❑ COMPLETE SERVICE ❑ METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: ❑ INSTALL BACKWATER VALVE(outside the building) ❑SFR ❑ SIDE SEWER CAP-OFF ❑ MULTI-FAMILY-#OF UNITS: ❑ SIDE SEWER RECONNECTION ❑ COMMERCIAL MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE: (circle desired size) ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR ❑ DOMESTIC: 3/4", 1", 2", OTHER: MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ IRRIGATION: 3/4", 1", 2", OTHER: ❑ i AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑ FIRE: 1", 2", 4", 6", 8", OTHER: SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER ❑ DOMESTIC/FIRE COMBO: 1", 2", OTHER: SINGLE OWNERSHIP. F/LL OUT REVERSE S1DE OF THIS FORM, CONTACT INFORMATION OWNER NAME: ; ��-,a. ��z. TENANT NAME(If Commercial): OWNER MAILING ADDRESS: sTREEr - Z - .�. R� v� CITY � ��YI-� -T� STATE J � ZIP OWNER PHONE: �� - �� I �Cfl� OWNER EMAIL: CONTRACTOR NAME: �' x„� c.�� CONTRACTOR ADDRESS: sTREer ��n, STATE Z�P t CONTRACTOR PHONE: 2 S - 2 — 13 �J COPlTRACTOR EMAIL: �„�; ,, �,i .,e' C�5 , co,�.-. CONTRACTOR LIC.#(REQUIRED): �1fV�� !� CITY OF EVERETT BUSWESS LIC #(REQUIRED): _.._..._...,.,.,_____�� . ..:.._.,_, ,...,...._.. ....� .:. ..�. �..�,._ __�x. PRIMARY CONTACT: ❑OWNER �CONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: ,�•��._ �s _ n ��ncz:y��I�-e.� �✓��'', CONTACT EMAIL: AGREEMENT.'The undersigned applicant ag�ees to comply wifh all provisions of the Evereff Municipal Code Title City of Everetf Offcial Use Only 94 Water and Sewer or such other rules and regulations now existing or which may be established from time to FEE time. The applicant fwther agrees, as a condifion precedent to receiving service that Elie ufilities division shall l�ave the right at any time,without notice,to shuf off or tum on the wafer supply forrepairs,construction,and nonpayment of charges or for any other reasonable cause.I am the owner, or I am authorized by the owner of this properfy to perform fhe work for which applicafion is made,and 1 comply with fhe State Confractors Law 98.27 pLRMIT# RCW and 6. OA W � � / (� ,Z S 20/��- I � � Owner/Au orized Agent Signature Date (Revised 90/1?J2095)