|
�V�G��'�� � �C���G�3 M�'0[�a��( /�(�p[��C�G��( ���
<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.gou/permits
<br /> PROJ�C�' SI`�'� IG49�'��iVi��'���
<br /> pROJECTADDRESS: Z� �� � ��'�'� S�
<br /> IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT#
<br /> BUILDING TYPE: CI�FR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? ❑ NO ❑YES, FROM TO
<br /> l�l'ILI'i'�( APPILICA'Y10[�➢ 1NF0liMIB►l'IO�d
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> I;�'S1DE 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 fhe 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/51ZE: (circle desired size}
<br /> ❑ I AM DECLINING MUL7IPLE DOMESTIC WATER SERV]CES FOR ❑ DOMESTIC: 3/4", 1", 2", OTHER:
<br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ IRR(GATION: 3/4", 1", 2", OTHER:
<br /> ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑ F1RE: 1", 2", 4", 6", 8", OTHER:
<br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER ❑ DOMESTIC/FIRE COMBO: 1", 2", OTHER:
<br /> SINGLE OWNERSHIP. F/LL OUT REVERSE SIDE OF THIS FORM.
<br /> CONTACT INFORMATION
<br /> OWNER NAME: d v��' �� U��d�Y TENANT NAME(lf Commerciaf}:
<br /> OWNER MAILING ADDRESS: sTREET 2�-O --- ��E� S�
<br /> CITY �t.v-�✓c
<br /> STATE V�J� Z�P
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME: `�� �1�=��'����
<br /> CONTRACTOR ADDRESS: srREEr �Z`"L�, `� Zl�'c�� �� �� ��`^+• ����5 �'�
<br /> CIN �n�"�l�- �l< STATE L,�1� ZIP S�'�
<br /> CONTRAGTOR PHONE: ��� —S(S5 CONTRAGTOR�MAIL: � �� • vi � ' 'L �-s�C�::..�
<br /> �. CITY OF EVERETT BUSINES LIC.#(REQUIRED):�j YZ� �}
<br /> CONTRAGTOR LIC.#(REQUIRED):C I `�l O , -.. _,..< ._.". -a-...,. _�:,___.:,,.,�.
<br /> .....,._�,._.._,,..,�_�.�,_ _.. �.._.._...,... _,_,.,,�.�.�,_._�. ,�.,
<br /> PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR ❑ OTHER(Please Specify)
<br /> CO AME: CONTACT PHOiVE: �2�= 7�j �- �� �
<br /> ����� -
<br /> COiUTACT EMAIL: �c; i,�� �L�,LS„� :C�- �,
<br /> AGREEMEN . e un ersigned applicant agrees to comply with all provisions of the Everett Municipal Code Tifle City of Everetf Official Use Only
<br /> 74 Water and Sewer or such ofher rules and regulations now existing or which may be established from time to FEL
<br /> time. The applicant further agrees, as a condition precedent to receiving service that the utifities division shall have � ' U�
<br /> the right at any time,withouf notice,to shut off or tum on the water supply forrepairs,construcfion,and
<br /> nonpaymenf of charges or for any other reasonable cause.I am the owner,or I am authorized Gy the owner of this
<br /> property to perforrn fhe work for which application is made,and I comply with the State Contractors Law 18.?_7 pERMIT#
<br /> R n 6.200A WAC_ � t � ( � + �j`��
<br /> � � — i�-- �- � v
<br /> Owner/Aufho � � nafurc Date (Revised 90/12/2015)
<br />
|