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<br /> CfTY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT,WA 98201
<br /> (P)425-257-8810 � FAX 425-257�8857 � (E) everefteps@everettwa.gov� www.evereftwa.gov/permits
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<br /> PROJECT ADDRESS: LY/l
<br /> IF APPLICA6LE: ❑OUTSIDE CfTY LIMITS ❑ BUILDIN6 AREA SF ❑ LOT#
<br /> BUILD(NG TYPE: ❑SFR-DETACNED ❑SFR-ATTRCHED ❑DULEX ❑MULTI-FAMILY�#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? �NO ❑YES, FROM TO
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<br /> � ''' 11TILITY APPLICA`ll'ION,INFORMATION- ' � `
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<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> j�l SIDE SEWER REPAIR ❑NEW WATER SERVICE INSTALLATION
<br /> ❑SIDE SEWER ALTERATION ❑COMPLETE SERVICE ❑METER ONI,Y •
<br /> ❑ NEW SIDE SEWER INSTALLATION SERVFCE/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 iYPE/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 OWNERSHtP. � �RRIGATION: 3/4", 1", 2", OTHEF2:
<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/FlF2E COMBO: 1", 2", OTHER:
<br /> SINGLE OWNERSHIP. FILL OUT REf/ERSE S/DE OF THIS FOR1Vl.
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<br /> ..- . ' CONTACT;INFORMATI,ON . -
<br /> OWNER NAME: U� TENANT NAME(lf Commercial):
<br /> OWNER MAILING ADDRESS: srReer ,���
<br /> CIIY � STATE ZIP q O
<br /> OWNHR PHONE: ��/ OWNER EMA[L:
<br /> CONTRACTOR NAME: �
<br /> CONTRACTOR ADDRESS: sraeer
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<br /> C�.n, STATE ZIP
<br /> CONTRACTOR PHONE• � � � 2 CONTRAC7�R EMAIL:
<br /> CONTRACTOR LIC.#(REQUlRED)- CITY OF EVERETT BUSINESS LIC.#(REQUIRED):
<br /> PRIMARY CONTACT: �CI OWNER ❑CONTRACTOR ❑OTNER(Please Specify)
<br /> CONTACT NAME• CONTAC7 PHONE: -- 3
<br /> COiVTACT EMAIL:
<br /> AGREEMEIVT.'The undersigned applicanf agrees to compty wifh all provisions of fhe Evereft Municipal Code Title City of Everetf Offcial Use Only
<br /> 94 lNafer and Sewer or such other rules and regulations now existing or which may be 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 af any time,without notice,to shut off or fum on the water supply forrepairs,construction,and
<br /> nonpaymenf of charges or for any other reasonab/e cause.l am the owner,or l am authorized by fhe owner of this
<br /> property pe rm the work for which application is made,and l comply tvifh fhe State Confractors Law 98.27 p�RMIT#
<br /> RCW a d 29 . 0 AC. � `��r ��
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<br /> r/Aufhorized Agent Signafure Date (Revised 90/12/2095) �
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