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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@evereftwa.gov � www.everettwa.gov/permits
<br /> PRO.J�C7' SIB'� I���RYVi�'�'9�N
<br /> PROJECT ADDRESS: i-.
<br /> 1F APPLICABLE: ❑ OUTSIDE C(TY LIM S ❑ BUILDING AREA SF ❑ LOT#
<br /> BUILDING TYPE: ❑SFR-DETACHED SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? �� ❑YES, FROM TO
<br /> �`�IL17'1( APPL.ICA'Y'9�9� Af�lFORtifiA,'�'901od
<br /> SEWER(check all that apply) WA7ER(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/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 /> SINGLEOWNERSHIP. FILLOU7REVERSESIDEOFTHISFORM.
<br /> CONTACT INFORMATION
<br /> OWNER NAME: • �z✓1 � TENANT NAME(If Commercial): :-'L�
<br /> OWNER MAILING ADDRESS: srREEr C�• ' �
<br /> CITY �' STA7E , ` ZIP /
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<br /> ,_ ,S c� �.�.�z � �"•�'�-�-� tr � �,c�
<br /> OWNER PHONE: �C�� �� �' C� OWNER EMAIL: •
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<br /> CONTRACTOR NAME: '' C " � J�
<br /> CONTRACTOR ADDRESS: srREEr � G � � i t f
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<br /> CITY ' � STATE ZIP
<br /> CONTRACTOR PHO(VE: �� �� ��( —� 5 COiVTRACTOR EMAIL: �Y1ClIw�U_ Z� r '�
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<br /> CONTRACTOR LIC,#(REQUIRED): � 'j l CITY OF EVERETT BUSINESS LIC REQUIRED): Cn� .5��
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<br /> PRIMARY CONTACT: OWNER ❑ CONTRACTOR ❑ OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: � '� � _
<br /> �`��� ��C'e CONTACT EMAIL: �i,� t �� � ' '� � lQ � 7 j�G
<br /> AGREEMENT.'The undersigned applicant agrees to comply wifh all provisions of the EvereK Municipal Code Title i y of erett Official Use Only
<br /> 14 Water and Seweror such ofher rules and regulations now existing or which may be established from time to FEE�� �h
<br /> time. The applicant further agrees, as a condition precedenf to receiving service that fhe utilities division shall have }�{, (�1
<br /> the righf at any time,without notice,fo shut off or turn on the wafer supply forrepairs,construction,and ��G�Y �
<br /> naipayment of charges or for any other reasonaGle cause.I am fl�e owner, or 1 am authorized Gy the owner of this
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<br /> property to perform fhe work f appiication is made,and I rom/�ly with fhe Sfate Confractors Law 18.27 PERMIT# �
<br /> RCW and 296200A W L'. � �
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<br /> Owner/Aufh ri d gent Sig af re Date (Revised 90/12/2095)
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