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_ -. CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT, WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857 1 (E) everetteps@everettwa.gov 1 www.everettwa.gov/permits
<br /> PROJECT SITE INFORMATION
<br /> PROJECT ADDRESS: 2 3 2 5 //. ,;�,h. A i t,
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? 0 NO 0 YES, FROM TO
<br /> UTILITY APPLICATION INFORMATION
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> *SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION
<br /> ❑SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY
<br /> ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE:
<br /> ❑ INSTALL BACKWATER VALVE(outside the building) 0 SFR
<br /> ❑SIDE SEWER CAP-OFF 0 MULTI-FAMILY-#OF UNITS:
<br /> ❑SIDE SEWER RECONNECTION 0 COMMERCIAL
<br /> MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE 1 SIZE:(circle desired size)
<br /> ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR 0 DOMESTIC: 3/4", 1", 2", OTHER:
<br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. 0 IRRIGATION: 3/4", 1", 2", OTHER:
<br /> ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER 0 FIRE: 1", 2", 4", 6", 8", OTHER:
<br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER 0 DOMESTIC/FIRE COMBO: 1", 2", OTHER:
<br /> SINGLE OWNERSHIP.FILL OUT REVERSE SIDE OF THIS FORM,
<br /> CONTACT INFORMATION
<br /> OWNER NAME: TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: sTREEr
<br /> CITY STATE ZIP
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME: / - cc
<br /> ._. I�c , �J,cs..,...: :,. ,. .: .._......�...._AT......z._.,....._. .. , u.,.. .
<br /> � .
<br /> CONTRACTOR ADDRESS: STREET 28' i 5 /S1 f' 5/l' � Q
<br /> CrrY Sr.,,7 c,,.C_ STATE kVA ZIP t j�j/Se
<br /> CONTRACTOR PHONE:)..00--.2 S.8-3,27 0 CONTRACTOR EMAIL: C./14"1,•,c,t? e Ai c kc t. c`t
<br /> CONTRACTOR LIC.#(REQUIRED): fk/Co TI—g�5 k Z CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 532 4
<br /> PRIMARY CONTACT: ❑OWNER CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: 2 S 3-so B-U 0
<br /> (-A ,, A ri f6 �e CONTACT EMAIL: tie 7/ec
<br /> � 6,14),,,....4,__, �?��,��. i.Lam*
<br /> AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title City of Everett Official Use Only
<br /> 14 Water and Sewer or such other rules and regulations now existing or which maybe established from time to FEE
<br /> time_The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have
<br /> the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,andr---
<br /> nonpayment of charges or for any other reasonable cause.lam the owner,or I am authorized by the owner of this 3r)
<br /> property to perform the work for ', application is made,and!comply with the State Contractors Law 18.27 PERMIT#
<br /> RCW and 29. OOA(NAC.
<br /> Age/
<br /> 3/7//6/ U 09.)- c( 2
<br /> Owner/Authorize:Agent Signature Date (Revised 10/12/2015)
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