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<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 320Q CEDAR STREET, EVERETT, WA 98201
<br /> (P)425-257�8810 � FAX 425-257�8857 � (E) everetteps@everetkwa.gov� www.everefitwa.gov/permits
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<br /> ' ; r <�� Pi�AJ�C'T' SI°�;E II�I�OR1�1,147101d' � ����
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<br /> ��.� ��� #4 ���_�����,
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<br /> PROJECT ADDRESS: Z. j
<br /> IF APPLICABLE: ❑OUTSIDE CITY LIMITS �7 BUILDIN6 AREA SF ❑ LOT#
<br /> BUILDING TYPE: ❑8FR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY�#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? �NO ❑YES, FROM TO
<br /> 11TIL17'Y APPLICATION INFOlZMA'f'lON _ � -
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<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 the building) ❑SFR
<br /> ❑SIDE SEWER CAP-OFF ❑MULTI-FAMILY-#OF UNtTS:
<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 ❑DOM'EST1C: 3/4", 1", 2", OTHER:
<br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ ►RRIGATION: 3/4", 1", 2", OTHER:
<br /> ❑�I AM�PTING 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. FlLL OUT REVE'RSE S/DE OF THIS FORIVI.
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<br /> _ CONTACT I,NFORMATION _
<br /> OWNER NAME• Qh1 � TENANT NAME(lf Commercial):
<br /> OWNER MAILING ADDRESS: STREET � 01 ✓� � �
<br /> C1lY STATE ZIP
<br /> OWNER PHONE: OWNER EMAIL:
<br /> COTITRA.CTOR NAME: Q C �
<br /> CONTRAC'TOR ADDRESS: s-rREEr
<br /> CIN STATE ZIP
<br /> CONTRACTOR PHONE: C0111TRACT�R EMAIi.:
<br /> CONTRACi'OR LIC.#(REC�UIRED)• CITY OF EVERETT BUSINESS LIC.#(REQUIRED): ��/O �
<br /> PRIMARY CONTACT:x.CIcOWNER �CI CONTRACTOR ❑OTNER(Please Specify)
<br /> CONTACT NAME•�r �„� � /� CONTACT PHONE: � ,.�.
<br /> � � ,�ilC�% COiVTACT EN(AIL:
<br /> AGREEMEIVT.�The undersigned applicant agrees to comply wifh all provisions of the Evereft Municipal Code Titfe City of Evereft Offcial Use Only
<br /> 94 Vl/aterand Sewerorsuch otherrules and regulafions now existing orwhich may be established from fime to FEE y��
<br /> fime.The applicant further agrees,as a condition precedent fo receiving service that the utilities division shall have v
<br /> the right at any time,without notice,to shut off or tum on the water supply forrepairs,construction,and /�b. �
<br /> nonpayment of charges or for any otherreasonable cause.I am the owner,or l am authorized by the owner of this
<br /> properfy fo perform the work for which li 'n is made,and 1 comply lvith the State Contractors Law 18.27 p�RMIT#
<br /> RCW and 296.200A W . ��,j� � i �� ,/S � /
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<br /> Owner/Aufh i Agent Signature Dafe (Revised 90/92/2095) �
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