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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 j www.everettwa.gov/permits
<br /> i`' # ° ` � ; PROJECT SITE INFOIt1ylAT10�+1;
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<br /> PROJECT ADDRESS:
<br /> IF APPLICABLE: ❑OUTSIDE CfTY LIMITS ❑ BUILDING AREA SF ❑ LOT#
<br /> BUILDING TYPE: ❑SFR—DETACHED ❑SFR—ATTACHED ❑DULEX ❑MULTI—FAMILY�#OF UN(TS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? NO ❑YES, FROM TO
<br /> UTILIT'Y APPLICATION INFORMATION
<br /> ,,. . _... _. _.. _ : _ __.. ..... . _ .
<br /> SEWER(check all that apply) WATER(check afl that apply)
<br /> ❑SIDE SEWER REPAIR � ❑ NEW WATER SERVICE INSTALLATION
<br /> ❑SIDE SEWER ALTERATION ❑GOMPLETE SERVICE . ❑METER ONLY
<br /> ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE:
<br /> �I INSTALL BACKWATER VALVE outside the buiiding) ❑SFR
<br /> ❑ SIDE SEWER CAP-OFF 0 MULTI-FAMILY-#OF UNITS:
<br /> ❑ SIDE SEWER RECONNEGTION . ❑COMMERCIAL
<br /> MULTIPLE DOMESTIG'WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE:(circle desired size)
<br /> ❑ 1 AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR ❑ DOMESTIC: 3/4", 1", 2", OTHER:
<br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ IRRIGATION: 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 DEVELOPMENT UNDER ❑ DOMESTIC/FIRE COMBO: 1", 2", OTHER:
<br /> SINGLE OWNERSHIP. F/LL OUT REVERSE S1DE OF THIS FORM.
<br /> CONTACT INFORMATION
<br /> OWNER NAME: TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET
<br /> C�7y STATE ZIP
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME:
<br /> CONTRACTOR ADDRESS: srReEr
<br /> CITY STATE � • ZIP
<br /> CONTRACTOR PHONE: � CO TRACTOR EMA(L:
<br /> CONTRACTOR LIC.#(REclU1RED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED): O
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<br /> PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: � CONTACT PHONE: � � ��'b Z
<br /> �`/�� �,��� YQ,"�� CONTACT EMAIL: .
<br /> AGREEMENT.•The undersigned applicanf agrees to comply with all provisions of the Evereft Municipal Code Title City of Everett Offcial Use Only
<br /> 14 lNater and Sewer or such ofher ru/es and regulations now existing or which may be estabfished from time fo FEE
<br /> fime.The applicant further agrees, a con i' precedent to receiving service that fhe utilifies division shall have � �^'6O
<br /> the right at any ' e,w' t notic ,to shut off o turn on the water supply for repairs,construction,and U �
<br /> nonpayment f ch r s or or an other reasona !e cause.I am fhe owner,or I am authorized by fhe owner of this
<br /> properfy to p or he wo hich applrcatio is made,and I compiy with fhe Sfate Contractors Law 18.27 PERMIT#
<br /> RCW and 29 200 WAC � � � t �Y I����
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<br /> wnerlAuthoriz gent Sig ature Date (Revised 90/12/2015)
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