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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
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<br /> _ ' � PROJ�CY SI`TE INFOI�I�i�'I'�ON, � ; �j �-
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<br /> PROJECT ADDf2ESS: � fL`T �I ���� Y� �"'
<br /> IF APPLICABLE: ❑�UTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT#
<br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX LTI-FAMILY�#OF UN1TS: ❑COMMERCIAL ❑1NDUSTRIAL
<br /> CHANGE OF USE? �' N� ❑YES, FROM TO
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<br /> : - 'i1TiLIT1f APPLIC�►7'IOId INFOLtMAT10M
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<br /> SEWER(check all that apply) WA'TER(check all that a.pply)
<br /> ❑SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION
<br /> �SIDE SEWER ALTERATiON ❑COMPLETE SERVICE ❑METER ONLY .
<br /> ❑ NEW SIDE SEWER INSTALLATION SERV(CE/METER USE:
<br /> ❑ INSTALL BACKWATER VALVE outside the building) ❑SFR
<br /> ❑SIDE SEWER CAP-OFF ❑MULTI-FAMILY-#OF UNITS:
<br /> ❑ SIDE SEWER RECONNECTION � ❑COMMERCtAL
<br /> MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVtCE TYPE!S1ZE:(circle desired size)
<br /> ❑ I AM DECLWING MULl'IPLE DOMESTIC WATER SERVICES FOR � ❑ D�iVfESTIC: 3/4", 1", 2", OTHER:
<br /> MY MULTI-FAMILY DEVELOPMENT UNQER SINGLE OWNERSHIP. ❑ IRRIGATION: 3/4", 1", 2", OTHER:
<br /> ❑ 1 AM OPTING TO INSTALL MULTIPLE DOI�IESTIC WATER ❑ FIRE: 1", 2", 4", 6", 8", OTHER:
<br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER ❑ pOMESTICiFIRE COMBO: 1", 2", OTHER:
<br /> SINGLE OWNERSHIP. FILL OUT REl/ERSE SIDE OF THIS FORNI.
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<br /> �` CONTACT INFORMATION . -
<br /> OWNER NAME• ,� T�NANT NAME(if Commercial):
<br /> OWNER MA1LiNG ADDRESS: STREET ,i�� `� � 0�
<br /> CITY �� STATE ZIP
<br /> OWNER.PHONE: ZS OWNER EMAIL: �, R
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<br /> CONTRACTOR NAME: � '— �'(T'(�t�t� S
<br /> CONTRACTOR ADDRESS: srReEr K— S O�
<br /> CIN STATE ZIP � �
<br /> CONTRA.CTOR PHONE: � l:�tv CONTRAC70R EMAIL: • �(��'I,�S� CC+S •�
<br /> COIVTRACTOR LIC.#(RE UtRED)• �1�9, S CITY OF EVE TT BUStNESS LIC.#(REQUIRED): ?
<br /> PRIMARY CONTACT:� �`OWNER m CONTRACTOR ❑OTHER(Please Specify)
<br /> CON7ACT NAM • CONTACT PHONE: s .�
<br /> �(IvI �"�"'"�',"� COIdTACT EMAIL: � `r �
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<br /> AGREEMENT.�The undersigned applicant agrees to comply with all provisions of the Fvereff Municipal Code f e City of Everett Official Use Only
<br /> 94 lNaterand Sewerorsuch other rules and regulations now existing orwhich may be established from time fo FEE
<br /> fime.The applicant further agrees, as a condition precedenf to receiving service that the utilities division shall have �D�Q
<br /> fhe right at any time,�vifhouf notice,to shut off or turn on the water supply forrepairs,construction,and �
<br /> nonpayment of charges or for any otherreasonaBle cause.I am the owner,or!am authorized by the owner of this
<br /> property to erform fhe wor for which bation is made,and I co ply wit the State Contractors Law 98.27 �'���'��
<br /> PERMIT#
<br /> RCW and .200A WAG. ` � �^D(r� Q��1
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<br /> Owner/ ufho zed Agent Signa e D te (Revised 90/12/2095)
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