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�i � C�� � �C�N�!I�� �J�I�f�Q�f� � 'pL�C�I�`�8��1
<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 � www.evereftwa.gov/permits
<br /> �RO�A��`�' S9�'� 9R����9�i�`11'0��
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<br /> PROJECTADDRESS: SpQ J�- ✓i�- ��
<br /> IF APPLfCABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT#
<br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: �COMMERCIAL ❑1NDU5TRIAL
<br /> CHANGE OF USE? 0 NO �YES, FROM } IL1�t�0��►�1 TO �G.1�^�O
<br /> ��s�o-�r w����c���o� a�a��r��a��ro��
<br /> SElIVER(check all that apply) WATER(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 BACKWATER 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 TYPE/SIZE: (circle desired size)
<br /> ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR ❑ D�MESTIC: 3/4", 1", 2", OTHER:
<br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNER5HIP. ❑ 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. FILL OUT REVERSE SIDE OF THIS FORM.
<br /> ' CONTACT INFORMATIOId
<br /> OWNER NAME: �.�.Tu S W��, TENANT NAME(If Commercial): �GI.LU..h-�
<br /> OWNER MAILING ADDRESS: sTReer�3�S .S� Y��`�-�'" ���'k" �""�S
<br /> CITY ��.t�• ��'-��• V STATE a EZ ZIP � I��S
<br /> �7 OWNER EMAfL• �'�V"s'�'���@ � G[-h�e�5 ' CAm
<br /> OWNER PHONE: 5D3 '(pc�3' �'�' Z'
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<br /> CONTRACTOR NAME: ('G ^ Y1f�Gl.��[ T t' P-vri �
<br /> CONTRACT01iADDRESS: sTt�EEr yZ��D �"(�" VF�i N E SV� `T�- ��'�
<br /> CITY ���`��Q/ STATE VlJ� ZIP q`�' ���
<br /> CONTRACTOR PHOPdE: Z-S'!T S�"�- $(lo� CONTR,4CT�R EIVIAIL: � ���""�Gv ����'-�� • ��
<br /> CONTRACTOR LIC.#(REQUIRED): GL- �NT� g��G� CITY OF EVERETT BUSINESS LIC #(REQUIRED): D S�SbD
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<br /> PRIMARY CONTACT: ❑OWNER l�'CONTRACTOR ❑ OTHER(Please Specify)
<br /> CONTAC7 NAME: J�� �J i��!� CONTACT PHOIVE: �'Z..s� "'j$'{- $((o$
<br /> CO�ITACT EIVIAIL: � W��.SOr���'��` �� � ��
<br /> AGREEMENT.�The undersigned applicant agrees to comply with a!I p�ovisions of the Everetf Municipal Code Tif/e City of Everett Otficial Use Only
<br /> 14 lNaterand Sewer orsuch other rules and regulations now existing or which may be established from time to FEE �
<br /> time. The applicant further agrees, as a condition precedent to receiving seivice that the ufilifies division shall have
<br /> fhe righf at any trme,without notice,to shut otf or fum on the wafer supp(y for�epai�s,consfruction,and �
<br /> nonpayment of charges or for any other reasonable cause.I am fhe owner,or I am authorized by the owner of this
<br /> property to perform the work for whic a plication is made,and 1 comply wifh the State Contractors Law 18.27 PERMIT#
<br /> RCW _96200A WA�
<br /> z� z��-t � 1 �7C l� �'��
<br /> Owne ufhorized Agent Signafure Date (Revised 90/92/2015)
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