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<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT,WA 98201
<br /> (P) 425-257-8810 i FAX A�25-257-8857 � (E) everetteps@everetfwa.gov � www.everettwa.gov/permits
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<br /> ����D��Y S➢'�'� d���RF�i�`�0�� ,
<br /> PROJECT ADDRESS: �p� � � � '�
<br /> IF APPLICABLE: ❑OUTSIDE CITY LIMITS ❑ BU]LDING AREA SF ❑ LOT#
<br /> BUILDINGTYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OFUNITS: f�COMMERCIAt ❑INDUSTRIAL
<br /> GHANGE OF USE? C7 NO �YES, FROM '� �c'�`��4� TO �
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<br /> �➢`r1A�0`�APP�1�.�+,'9'�O� �Id���f�id�"`�"9�R�
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<br /> SEVI/ER(check all that apply) WATER(check all that apply)
<br /> ❑SIDE SEWER REPAIR ❑ NEW WATER SERVICE 1NSTALLATION
<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 UNfTS:
<br /> ❑ SIDE SEWER RECONNECTION ❑ COMMERCIAL
<br /> MUL.TIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SiZE: (circle desired size)
<br /> ❑ I AM DECLINING MUL-fIPLE DONIESTIC WATER SERVICES FOR ❑ DOMESTIC: 3/4", 1", 2", OTHER:
<br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ IRRIGATION: 3/4", 1", 2", OTHER:
<br /> ❑ 1 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 SIDE OF THIS FORM.
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<br /> ' CONI'ACT INFORMATION.
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<br /> OWNER NAME: [�'�'�'S W � TENANT NAME(If Commercial): �A,(,0�..�-�
<br /> OWNERMAILINGADDRESS: srReEr��S .SV�.� 1�'�toW`o�`�" c�V�'� 2'"1�
<br /> CIN ��..lG'L l/�V°�G (� STATE �• � ZIP �7��S
<br /> OWNER PHONE: SD�j �(oc�3- `t��3 OWNER EMAIL: �'��'"'��°^@ �' ��� • G°�"
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<br /> COIVTRAGTOR NAME: ('Ga ^ Yt�A.h� � r V2�'1 �
<br /> CONTRACTOfZ ADDRESS: sTReEr �tt70. ��' P[Vt% N�/ �V►T�- ��"�
<br /> CITY �/���u"Q/ STATE t�V' 1 ZIP ���a�
<br /> COAITRACTOR PHONE: Z>S���"F" $(�� CONTRACTOR EMAIL: � ���"'�G� ����'��� • ��
<br /> CONTRACTOR LIC.#(REQUIRED): u-��'t'� g�''�"G� CITY OF EVERETT SUSINESS LIC.#(REQUIRED)rv C�S�oS�D_s,^
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<br /> PRIMARY CONTACT: ❑OWNER I�'CONTRACTOR ❑ OTHER(Please Specify)
<br /> CONTACT NAME: J p� ����f1 CONTACT PHONE: �2,�'� "f�j�{- $'j(o$
<br /> COf�TACTEIViAIL: ` W��SOr��--a�'C�n` �� . ��
<br /> AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Evereit Municipal Code Tifle City of Everett Official Use Only
<br /> 14 Water and Sewer or such other rules and regulations now existing or which may be estaGlished f�om time fo FEE
<br /> time.The applicanf fudher agrees, as a condition precedent to receiving service that fhe utilities division shall have �' �!
<br /> the right at any time,v✓ithout notice,to shut off or tum on the water supply forrepairs,construcfion,and l � �
<br /> nonpayment of charges o�for any otherreasonable cause.1 am the owner,or I am authorized by the owner of this
<br /> property to pe�form tl�e v✓ork for whic a pl�cation is made,and 1 comply with the Sfate Contractors Law 98.27 PERMIT#
<br /> RCW 96200A WA��
<br /> z� ��� � � 7 G� l -C�� 7
<br /> Owner uthorized Agent Signafure Date (Revised 10/1212015)
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