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����� � ����� ������� ����0������ <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'I' SI'YE IPIFORMI�'r10P1 <br /> PROJECTADDRESS: �(�%C�`CF3 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 U5E? �NO ❑YES, FROM TO <br /> lJT1�ITY APPLICATION INFORMATIOPI <br /> SEWER(check all that apply) WATER(check all that apply) <br /> L'�I SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION <br /> ❑ SIDE SEWER ALTERATION ❑ COMPLETE SERVICE ❑ METER ONLY <br /> ❑ NEW SIDE SEWER INSTALLATfON SERVICE/METER USE: <br /> ❑ INSTALL BACKINATER 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. FILL OUT REVERSE SIDE OF THIS FORM. <br /> CONTACT INFORMATION <br /> OWNER NAME: v r`v..�'�'.c�ti� �j`l�.�t� TENANT NAME(If Commercial): <br /> '- r `l�. <br /> OWNER MAILING ADDRESS: sTRFFr � ��,��' �'� �'"'t-'�-a' � �� <br /> � ,. �[ r./�'��" ' - [j <br /> CITY �V(�.'�b �v STATE �� � Z�P � <br /> OWNER PHONE: �'� '� 7��' y �� Z L6 OWNER EMAIL: '� <br /> CONTRACTOR NAME: 1'�l _.:C At �r' r'�h �'� �'` ' �'� '" E�a'',� ��-�' <br /> '� ���t��,,.._, lf.� . � � � <br /> CONTRACTOR ADDRESS: srREET �� �%'..e R.t �`+ �.� � p°� <br /> T��� '�" ,��`� CITY Ll,I �� STATE �'' .4 �?k.:.� ZIP <br /> .��,��, i� , .... <br /> CONTRACTOR PHONE: � �J�:���� �`"��~���I CONTRACTOR EMAIL: �\�.��� 4 ��14--�-.�"'�'-��%��"`� l.� . ° r� <br /> ��`�•-� <br /> CONTRACTOR LIC.#(REQUIRED): ,' 'L� -_�.����i)�;'?,.�-3� �-�. CITY OF EVERETT BUSINESS LIC.#(REQUIRED): `• �7�-}-��`-� <br /> PRIMARY CONTACT: ❑OWNER E�CONTRACTOR ❑ OTHER(Please Specify) <br /> CONTACT NAM,�:,� _ CONTACT PHONE: (L•f��� `�.���- —�"��� <br /> � __.. �.. f <br /> � CONTACT EMAIL: `� � ( -�'"�"� �� ` <br /> . <br /> �' { ; { � �: t :t tiJ1.C`l i o^( C�.-i .LiG- l�=` L � � � :�✓l <br /> AGREEMENT.�The undersrgned applicant agrees to comply with aI!provisions of the Everett Municipal Code Title Cify of E erett Official Use Only <br /> 14 Water and Sewer or such other rules and regulations now existing or which may be esfab/ished from time to FEE �1 � <br /> time.The applicanf further ayrees,as a condition precedent to receiving service that the utilities division shall have ,t.� <br /> U / <br /> the rght at any time,m�ithout notice, to shut off or tum on the water supply for repairs,construction,and ,\ i f <br /> nonpayment of charges or for any other reasona6le cause.1 am the owner,or 1 am authorized by the owner of fhis <br /> property to perfoim the wo�k for whi piication is made,and I comply with the State Contractors Law 18.27 PERMIT# <br /> RCW and 296.7.00A WA�. � � � ��� <br /> , �' •z-' �Z - ��1 � �� <br /> , .,. , <br /> Owner/Autho ze A'ent Signa re Date (Revised 10/12/2015) <br /> � <br />