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<br /> t' C(TY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT, WA 98201
<br /> (P)425-257-8810 � FAX 425-2�7-8857 � (E) everetteps@eueretiwa.gov( www.everetiwa.goulpermits
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<br /> �"$ ' � � �� ����� ���" � _ .p O�C�7��SITE�INFOR ATI�Nx �a�° _� _�
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<br /> PROJECTADQIZESS: �6 . � ��� �U� w�
<br /> IF APPLICABLE: ❑OU7SIDE C1TY LIMITS ❑ BUILDING AREA SF ❑ LOT#
<br /> BUILDING?YPE: ❑8FR-DETACHED 17SFR ATTACHED 17DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF US�? �� ❑YES, FROM TO
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<br /> � q� �'" "�, ` �` UTILITY APPLICATION,INFORMATION ,�. �¢. : � � ��,,::. ,:,.5��
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<br /> r � SEWER(check all that apply) WATER(check all fhat apply)
<br /> DE SEWER REPAIR ❑ NEW WATER SERVICE 1NSTALLATION
<br /> ❑SIDE SEWER ALTERATION ❑COMPLETE SERVICE ❑METER ONLY
<br /> ❑ NEW SIDE SEWER INSTALIATION SERVICE/METER USE:
<br /> ❑ INSTALL BACKWATER VALVE outside fhe building) ❑SFR
<br /> ❑SIDE SEWER CAP-OFF ❑MULTI-FAMILY-#OF UNITS:
<br /> ❑ S1DE SEWER RECONNEC710N � ❑GOMMERCIAL
<br /> MULTIPLE DOMESTIC WA?ER SERViCES REQUEST WATER SERVICE TYPE/SIZE:(circte desired size) ,
<br /> ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR ❑ DOMESTIC: 3/4", 1", 2", OTHER:
<br /> MY MULTI-FAMILY DEVELOPMENT UNDER S)NGLE OWNERSHIP_ ❑ �RRIGATION: 3I4", 1", 2", OTHER:
<br /> L7�i AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑FIRE: 1", 2", 4", 6", 8", OTHER:
<br /> SERVICES FOR MY MULTI-FAMILYDEVELOPMENT UNDER ❑ QOMESTfC/FIRE COMBO: 9", 2", OTHER:
<br /> SWGLE OVI/NERSHIP. FILL OU7REVERSE S/DE OF THIS FORNI. '
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<br /> ,����� , CONTACT I�iFORMATION
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<br /> OWNEit NAME• �q� r �i C��� �r TENANT f11AME(If Commercial):
<br /> OWNER MAILING ADDRESS: s��r �D� �j(� � �
<br /> CIN . . STATE �V �' �P� I7��
<br /> OWNER PHONE• OWNER EMAIL• _
<br /> CONTRACTOR�NAME• N ��O a N B�
<br /> CONTRAC7'OR ADDRESS: �-rtzeEr � S� F�Uf y l ����n� � � �"u
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<br /> -GONTRACTOR PHONE: ��. �. � D CONTRACTaR EMAIL:
<br /> ''�� CONTRACTOR LIC.#(RECIUIRED)• �G `� �� � 1� CITY OF EVERETT SUSINESS LIC.#{REQUIRED-
<br /> F�RIMARY CONTACT: ❑OWNER M �ONTRACTOR ❑OTHER(Pfease Specifiy)
<br />` CONTACT NAME: CONTAC'f PHONE: pZs � �,p�. ��
<br /> �� C �! ��.�����a� CONTACT EMAIL:
<br /> AGREEMENT.'The undersigned applicant agrees fo comply with aI!provisions of fhe Everetf Municipal Code Title City of Everetf Official Use Only
<br /> 14 Vl/ater and Seweror such other rules and regulations now existing orwhich may 6e estab/ished fmm time to FEE
<br /> time.The applicant further agrees,as a condition precedent to receiving service that the utilities division shail have �_
<br /> fhe right af any time,without notice,to shut off or turn on the water supply for repairs,construction,and
<br /> nonpayment of charges or for any otherreasonable cause.I am the owner,or!am authorized by the owner of this ���
<br /> properfy to perform the work for which application is made,and!comply with fhe State Contractors Law 98.27 PERMIT#
<br /> RCW 296.20DA WAC. --. � � s �o�� � ��� � ��
<br /> Owner/Authorized Agent Signafure Date (Revised 90/92/2095J �
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