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<br /> C1TY OF EVERETT PERMfT SERVICES
<br /> 3200 CEDAR STREET, EVERETT,WA 98201
<br /> (P)425-257-8810 � FAX 425-257-8857 J (E) everetteps@everettwa.gov� www.everettwa.gov/permits
<br /> ' � PROJ�C7'SI'T'E IN�OttMA`t10N.
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<br /> PROJECTADDRESS: � 08� � p� �� STr2EF7� � S�
<br /> IF APPL(CABLE: ❑OUTSIDE CITY LIMITS ❑ BUILDWG AREA SF ❑ LOT#
<br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY�#OF UNITS: ❑COMMERCIAL ❑iNDUSTRIAL
<br /> CHANGE OF USE? �NO ❑YES, FROM TO
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<br /> � LI'i'ILITY APPLICA'i'ION INFORIVIATIOhI ` ,
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<br /> SEWER(chec[c all that apply) WA?ER(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 BACKINATER 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 NPE/SiZE: (circle desired size)
<br /> ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR ❑ DOM'ESTIC: 314", 1", 2", OTHER:
<br /> MY MULTI-FAMlLY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ �RRIGATION: 3/4", 1'; 2", OTHER:
<br /> ❑�I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑ FIRE: 1", 2", 4", 6", 8", OTHER:
<br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMEN7'UNDER ❑ DOMESTIC/FtRE COMBO: 1", 2", OTH.ER:
<br /> SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORNI.
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<br /> CONTACT INFORMATION;
<br /> OWNER NAME: �} 2 � /V E w� p TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET � �J o� �� � sr -S�',�� ET SE
<br /> crrv E V E R E 7-�- sTn-r� I vA ziP o2 �6
<br /> OWNER PHONE: a o 6-a a 6� ��5� OWNER EMA[L:
<br /> COIVTRAGTOR NAME: SA ^^E A,_$' 8 D v�
<br /> CONTRACTOR ADDRESS: sTReer
<br /> CITY STATE ZIP
<br /> CONTRACT�R PNONE: CONTRACTOR EMAIL; -
<br /> CONTRACTOR LiC.#(REQUIRED)• ' CITY OF EVERETT BU5INESS LIC.#(REQUIRED):
<br /> PR(MARY`CON7ACT:��OWNER��CI CONTRACTOR ❑ OTHER(Please Specify)
<br /> CONTACT NAME; CONTACT PHONE:
<br /> CONTACT EMAIL:
<br /> AGREEMENT.'The undersigned applicant agrees to comply with a1/provisions of the Everett Municipal Code Title Cify of Evereft Offtcial Use Only
<br /> 94 Water and Sewer or such other rules and regulafions now existing or which may be established from time fo FEE
<br /> time.The applicant furfher agrees, as a condition precedent to receiving service that the utilities division shall have .
<br /> the right at any time,without notice,to shut off or tum on the water supply forrepairs,consfruction,and �""—'
<br /> nonpayment of charges or for any otherreasonable cause.I am the owner,or 1 am authorized by the owner of fhis
<br /> property to perform the work for which application is made,and I comply with the Sfate Confractors Law 98.27 PERMIT#
<br /> RCVI/and 296.200A WAC.
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<br /> Owner/Authorized Agent Signature _ Date (Revised 90/92/2095)
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