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<br /> � CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT,WA 98201
<br /> (P)425-257-883 0 � FAX 425-257-8857 � (E) everetteps@everettwa.gov � www.everettwa.gou/permits
<br /> �- PROJECT SITE INFORMATION � �
<br /> $ f. �.� i�� ��� � ��'� " �.`sP� .._Y
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<br /> PROJECT ADDRESS: ��� Z- � �� � � � �� Z �
<br /> 1F APPLtCABLE: ❑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? ❑YES, FROM TO
<br /> E � UTILITY APPLICATION INFORMATION ��� i ��� j °� ; t' �~�� �`
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<br /> SEWER(check all that apply) WATER{check all that apply)
<br /> �DE 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-FAM(LY-#OF UNITS:
<br /> ❑ SIDE SEWER RECONNECTION ❑COMMERCIAL
<br /> MULTIPLE DOMESTIC WATER SERVIGES REQUEST WATER SERVICETYPE/S1ZE: (circle desired size�
<br /> ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICEB FOR ❑ DOMESTIC: 3/4", 1", 2", OTHER:
<br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ �RRIGATION: 3/4", 1", 2", OTHER:
<br /> ❑�t AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑ F1RE: 9", 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 SlDE OF THIS FORNI.
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<br /> ° ONTACT INFORMATION
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<br /> OWNER NAME• /� � �r Di�i- � TENANT NAME(If Commercial): � Q C �
<br /> OWNER MAILING ADDRESS: sTReer (o p Lo �
<br /> CIN � �/Q� ' STATE Z�P
<br /> OWNER PHONE: ��Z� '- �Z �Zn�- OWNER EMAIL:
<br /> COIVTRACTOR NAME: Q v"
<br /> CONTRACTOR ADDRESS: sTReer � .p Cc, � �c��-v,- - � '
<br /> CITY � STATE �f ZIP � �j D
<br /> CONTRACTOR PNONE: � ��-� � - .v CONTRACTOR EMAIL: � '(?�� � �-i �`(��- � C Q Y
<br /> CONTRACTOR LIC.#(REQUIRED)• Q � �, Z Z 1TY OF EVERETT USINESS LIC.#(REQUIRED): ��Z Z
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<br /> PRIMARY CONTACT: ❑OWNER I�ONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: Z _ p�`_ ��j
<br /> �Ati-,�e-- ��O w�.�,.� CONTACT EMAIL: ^ Gl�/1�� �j�a w cn;�.. \" - d.,," � �
<br /> AGREEMENT.�The undersigned applicant agrees to comply with all provisions of the Evereff Municipal Code Title C�ty of Everett Official Use Only
<br /> 14 VUater and Sewer or such other rules and regulations now existing or which may be established from time to FEE�
<br /> time.The applicant further agrees,as a condifion precedent to receiving service thaf the utilities division shall have �_
<br /> the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and
<br /> nonpayment of charges or for any other reasonab/e cause.I am fhe owner,or l am authorized by fhe owner of this
<br /> property to perform the work for which application is made,and 1 comply with the State Contractors Law 98.27 PER IT /�`�
<br /> RCW and 296 OOA I(YAC. � ��( C �/��( J
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<br /> OwnerlA �ized Agent Signature ate (Revised 90/12/2095)
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