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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) e�eretteps@everetiwa.gov � www.everettwa.gov/permits
<br /> PROJ�C'➢' SI`�l� 94��'�RtVI�'�90f�
<br /> PROJECT ADDRESS: � t� �:��`-'��� -t%` � `}� �
<br /> IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILQING AREA SF ❑ LOT#
<br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? �ND ❑YES, FROM TO
<br /> 9�`TIL17'l( APPLiC6�`Y°ION 9�FORIVaA�'109d
<br /> SEVI/ER(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/51ZE: (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 ❑ 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 DUT REVERSE SIDE OF THIS FORM.
<br /> CONTACT INFORMATION
<br /> WNER NAME: `M� LnyC�L��- C .� `Z- TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: srREEr �- `'l� S
<br /> ciTv ��,��.^e,�' srnTe W�1 zia ���.
<br /> O NER PHONE: �'c�j� �-��� ���� OWNER EMAIL: �`(l�(,..R.�w��K—��.-.�' ` �
<br /> _ ..._,.� ._�,... . . ,__�,.._ . .�....._. .....,��.. ,�.
<br /> ONTRACTOR NAME: l�' Sl. � �r� C� x C�`l ����'t �-L C.
<br /> CONTRACTOR ADDRESS: srREEr p�Yx� G..� S )�J��� S�. q $� v
<br /> �"'� C�l.e� �S C --�7..�-.� l,� CITY �G� l�. STATE - ZIP / x� C, G
<br /> CONTRACTOR PHOIVE: ��jL�O 1 �I����G 3�S COPITRACTOR EMAIL: � �� �`J�l � 1�'�-��'"��t,'1 � �^
<br /> CONTRACTOR LIC.#(REQUIRED): �2-1 C i L UC? JIC-Z CITY OF EVERETT BUSINESS LIC #(REQUIRED): c� J�� �
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<br /> �..w._n_�.,.:__.v_�...�_ ,.....,> , _�._,.... . _-....,_.-., . _,....�,._ �.... .. -
<br /> PRIMARY CONTACT: 'E�WNER ❑CONTRACTOR ❑ OTHER(Please Specify) 1�(1 ' �--` �
<br /> CONTACT NAME: CONTACT PHONE: �—(�.��� `�cJ 3 �� ��
<br /> U�n �C�,� � �- ti.� CO�ITACT EMAIL:
<br /> t y 11 ��,1.�;�`'Z- �i v`- C�1�(�,;.�C��..,�C. �Y L'., 2��/�
<br /> AGREEMENT.'7 he undersigned applicanf agrees to comply with all provisions of the F_veretf Municipal Code Title City of Evereff Offcial Use Only
<br /> 94 Wafer and Sewerorsuch otherndes and regulations now existing or which may be established from time to FE�
<br /> time. The applicanf further agrees, as a condition precedent to receiving service thaf the ufilities division shall have � �
<br /> the right af any time,without notice,to shut off orturn on the watersupply forrepairs,construction,and i�l I �--� •��
<br /> nonpayment of charges or for any otherreasonable cause,I am fhe owner,or I am aufhorized by the owner of this
<br /> �
<br /> properfy to perform fhe work for v✓hich application is made,and I comply with the State Contractors Law 18.27 PERMIT#
<br /> RCW and?_96 OOA WAC.
<br /> .� � )b ��/i � � � � � �� ,
<br /> Owner/Authorized Agent Signature Date (Revised 90/12/2095)
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