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�T�� 1 �� �� ��'�LA� L 9�.��9�6�
<br /> CITY OF EVERETT PERMIT S �CES
<br /> 3200 CEDAR STREET, EVERETT, WA 9820�
<br /> (P)425-257-8810 � FAX 42�-257-8857 � (E)everetteps@everetfwa.gov� www.evereitwa.gov/permits
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<br /> _ � PRO.IEC°i° SI'T� IId��RI�A7`iON :. .
<br /> PROJECT.4DDRESS: ,S(?S [�G �..s,;,o p�
<br /> 1F APPLICABLE: ❑OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT#
<br /> SUILDING'TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑CdMMERCIAL ❑INDUSTRiAC
<br /> CHANGE OF USE? ❑NO ❑YES, FROM TO
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<br /> 11T1�i1i`Y APPL.ICATION INIFORM�ITION -
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> SI.DE SEWER REPAIR ❑NEW WATER SERVICE INSTALLATION
<br /> ❑SIDE SEWER ALTERATION ❑ COMPLETE SERVICE ❑METER ONLY
<br /> ❑ NEW S1DE SEWER INSTALLATION SERVICE/METER US�:
<br /> ❑ INSTALL BACKWATER VALVE(outside the building) ❑5FR
<br /> �SIDE SEWER CAP-OFF ❑MULTI-FAMILY-#OF UWTS:
<br /> ❑S1DE SEWER RECONNECTION ❑COMMERCIAL
<br /> MULTIPLE DOMESTIG WATER SERVICES REQUEST WATER SERVICE TYPE/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 OWNERSHlP. ❑)RR(GATION: 3/4", 1", 2", OTHER:
<br /> ❑ I AM OPTING TO INS7ALL MULTIPLE DOMESTIC WATER �FIRE: 1", 2", 4", 6", 8", OTHER:
<br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER ❑pOMESTIC/FIRE COMBO: 1", 2", OTHER:
<br /> SINGLE OWNERSHIP.FILL OUT REVERSE S1DE OF THlS FORM.
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<br /> � � � CONTACT. INFORMATION _
<br /> OWNER NAME: ��w• �„a��� TENANT NAME(if Commercial):
<br /> OWNER MAILING ADDRESS: s�x�r
<br /> Cf1Y STATE ZIP
<br /> OWNER PHONE: �2.$-a�3�6��/ OWNER EMAlL:
<br /> CONTRACTOR NAME: �,%o� �%c��,../ry 4-S. - - -- -
<br /> CONTRACTOR ADDRESS: s-rRee-r � .7 /5 �� b/
<br /> crrr e��.,e_ sTa� l.. � ziP r�'`�
<br /> CONTf2ACTOR PHONE:z�3�,�0�'O�v CONTRAGTOR EMAIL: G/�,�.�, ,>�6� e�,��
<br /> COPITRACTOR LIG.#(REQUIRED): /t„��� TL, 6�fLZ CITY OF EVERETT BUSINESS LIG.#(REQUIRED): ��S 3 Z I
<br /> Mr.�z.T -�._e.,,�.,�..�.,�..u:�..�.�,,.��.,�.w=z=z._v.�.,:�...�.:�.�...�.rJ.,.a,,..,.,n.,,.......,c,Y��_�__�,....�_�w�.�-Y,�._.z....�..,...a�.�..H.,,YF„u:_.�.._y.,�._��._..�m�..,.�._.._,.r.�..e,p_f_.�,..�v,�r.�,..�.,.�Ry__,-
<br /> PRIMARY CONTACT: ❑OWNER [,�CONTRACTOR L7 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: S' — Sp�- D g(C}
<br /> �� ,' �b,,t f� �,� CONTACT EMAIL: �,� � � ���,�r„�
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<br /> AGREEMENT.•The undersigned applicant agrees to comply with all provisions of fhe Everett Manicipal Code Title City of Evereit Official Use Only
<br /> 94 Water and Sewer or such other rules and regulations now existing or which may be esta6lished from time to FEE
<br /> fime.The applicant further agrees,as a condition precedent to receiving service that ihe ufilities division shell have �n ^ p���
<br /> the righf af any time,wifhout nolice,to shut off or turn on the wafer supply for repairs,construction,and ��� V
<br /> nonpaymenf of charges or for any other reasonable cause.l am the owner,or 1 am authorized by the owner of this �
<br /> properiy to perform ihe work for which applicafion is made,and 1 comply with the State Contractors Law 98.27 ���-�-# ���
<br /> RCW and 29 .200A WAC. �/�j/� � � I /
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<br /> Owner/Aufhorized Agent Signature Date (Revised 90/9?J2095)
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