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<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 SIYE INFORMATION
<br /> PROJECTADDRESS: G'�"� (� �� f-u�_�-r�}�'� �-'r� L���cD�r:
<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 APPLICATIOW INFORMATION
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> �IDE 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. F1LL OUT REVERSE SIDE OF THIS FORM.
<br /> CONTACT INFORMATION
<br /> OWNER NAME: ��� '�--('� �1'1� �1�-� TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: sTReET e1`�Z� .(� %�
<br /> GTY "' �Q��. STATE L�� � ZIP �� `
<br /> OWNER PHONE: ��' � OWNER EMAIL: %L� -�-
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<br /> CONTRACTOR NAME: , ' �r� C,�11�'7'" � V kl��r
<br /> CONTRACTOR ADDRESS: sTReer �jZ� �{DI ��t J � `-�t
<br /> CITY � STATE 'r;U� Z�P -0�
<br /> CONTRACTOR PHONE: (��c :�.�,I7�7 CONTRACTOR EMAIL: N `
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<br /> CONTRACTOR LIC.#(REQUIRED): S ��:� (,ti� ��7 C��c� CITY OF EVERETT BUSINESS LIC.#(REQUIRED).�i� �CZ`�=
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<br /> PRIMARY CONTACT: ❑OWNER ONTRACTOR ❑ OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: �f C� �� —���
<br /> ��r"��O� �'�I e Y'lC�� GL�� CONTACT EMAIL: '��(j� ,�i C-(1�cL-l� � i C �C�� , c .� in
<br /> AGREEMENT:The undersigned applicanf agrees to comply with all provisions of the Everett Munrcipal Code Title City of Everett Official Use Only
<br /> 14 Water and Sewer or such other rules and regulations now existing or which may be established from fime to FEE
<br /> fime. The applicant further agrees, as a condition precedent fo receiving service that the utilities division shall have �� ¢\ �
<br /> the righf at any time,without notice,to shut off or turn on the water supply fo�repairs, construction,and `�
<br /> nonpayment of charges or fo�any other reasonable cause.I am the owner,or 1 am authorized by the owner of this
<br /> property to perform the wo�k for which applrcafion is made,and!comply with the Sfate Contractors Law 18.27 PERMIT#
<br /> RCW and 296.2 WAC. � I �]�( � � Dr �
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<br /> Owner/Aufhorized Agent Signature Date (Revised 10/92/2015)
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