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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 /> PROJ�C`�' �1`�'� A����IVi��'9��
<br /> PROJECT ADDRESS; � � I —I C�r��h �V�. �v�%�`r� w� ����
<br /> IF APPLICABLE: ❑ OUTSIDE GITY LIMITS ❑ BUILDING AREA SF ❑ LOT#
<br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHAPIGE OF USE? �NO ❑YES, FROM TO
<br /> �TILITI( APPLICA`�'109�➢ ��iFORIlIdIA�"�`IOHd
<br /> SEWER(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 fhe building) ❑ SFR
<br /> ❑ SIDE SEWER CAP-OFF ❑ MULTI-FAMILY-#OF UNITS:
<br /> ❑ SIDE SEWER RECONNECTION ❑ COMMERCIAL
<br /> MULTIPLE DOMESTIC WATER SERVICES REQUES7 WATER SERVICE TYPE/SIZE: (circle desired size)
<br /> ❑ I AM DECLWING 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 OUT REVERSE SIDE OF THIS FORM.
<br /> CONTACT INFORMATION
<br /> OWNER NAME: C�'(�'R�- e,� �� : I"�i:�'f L TENANT NAME(If Commercial):
<br /> OWNER MAILWG ADDRESS: srREEr y � I '1 C`�P'C.�.Y� L°Z
<br /> f STATE G( �P ��O
<br /> CITY �U���e.�
<br /> 1 � � �
<br /> OWNER PHONE: "1�`5l� �� OWNER EMAIL:
<br /> .,.._.� ..�,.�;� ,_..�._,... ..,.,� ..._�._.,.�..,..„ i
<br /> . ., ._�...- ,,,_a�:., ��...,. �...._. ,.."�._....,,...�_......�....�,..�_.. ....._, __�,. ..
<br /> OIVTRACTOR NAME: t� 1 Y�'�, �::,,V1 ' L-�: � I� � "�"M�
<br /> l �i1 �
<br /> CONTRACTOR ADDRESS: srREEr � �� � � �
<br /> �C��d�. �U I`Y.: I���;�',crrv STATE . ' �Ct� ziP �
<br /> CONTRACTOR PHONE: �G?"���-I I`1 � CONTRACTOR EMAIL: �.�;�V'�'C�C l.`����'"Lu��� 5�'`'"�CG1�j
<br /> �
<br /> C(TY OF EVERETT BU5INESS LfC #(REQUIRED): ��..1��0� V
<br /> CONTRACTOR LIC.#(REQUIRED): ��- �� ,.�_. , .�_...., ..r:�,. .o.�..
<br /> _..w ,.,..�____�_�..�:_... _: _,,,, ..._„.,,�._.__......�.
<br /> PRIMARY CONTACT: ❑OWNER �CONTRACTOR ❑ OTHER(Please Specify)
<br /> GONTACT NAME: CONTACT PHOIVE: �,Q(d_ l��•-�j���4�
<br /> �� l ;� r* '�', q
<br /> rIL6`. ��Cti�l6V�C5 CO�ITACTEMAIL: J--�-_ Y'\_�.���� �` ti� � 'i'��L c9�C_V� .C.;�.�1
<br /> AGREEMENT.�The undersigned applicant agrees to comply with all provisions of the Everetf Municipal Code Tifle City of Everett Offcial Use Only
<br /> 14 Water and Seweror such other rules and regulations now existing or which may be esfablisl�ed from fime to �
<br /> time.The applicant further agrees, as a condifion precedent to�eceiving service that the utilifies division shall have FEE ��. ;� ��
<br /> , vy�,�,
<br /> the righf af any time,withouf notice,to shut off or tum on the water supp/y forrepairs,construction,and ���
<br /> nonpayment of charges or for any other reasonable cause.I am the owner, or I am authorized by the owner of this
<br /> properfy to pe�form the wo�k for which appiication is made,and!comply with the Sfate Confractors I_aw 98.27 �I�/�IT# � � �
<br /> CWa 96.20 J � I� I
<br /> � . � - t/�3� �( 7
<br /> Owner/Aufhorized Agent Signature Date (Revised 90/12/2095)
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