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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@everetlwa.gov� www.everettwa.gov/permits
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<br /> PROJECT ADDRESS: f� --- v" Q h w�
<br /> IF APPLICA6LE: ❑OUTSIDE CITY LIMITS ❑ BUILQING AREA SF ❑ LOT#
<br /> BUlLDING 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 /> ` 1JTIL.ITI(APPLIC�►'i°ION INPORMATI;�� ,' , �
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<br /> SEWER(check all that apply) WA heck all that appiy)
<br /> ❑S1DE 5EU1/ER REPAIR ❑NEW WATER SERVICE INSTALLATION
<br /> SIDE SEWER ALTERATION ❑COMPLETE SERVICE ❑METER ONLY �
<br /> � NEW 51DE SEWER INSTALLATION SERVtCE/METER USE:
<br /> ❑ INSTALL BACKWATER VALVE oufside fhe buiiding) ❑SFR
<br /> ❑ SIDE SEWER CAP-OFF ❑MULTI-FAMILY-#OF UNiTS:
<br /> � SIDE SEWER RECONNECTION ❑COMMERCIAL
<br /> ���� T1C WATER SERVICES REQUEST WATER BERVICE TYPE 1 S1ZE: (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. ❑ �RR(GATION: 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 SIDE OF THIS FORM:
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<br /> ` CONTACT I,NFORMATION � _ -
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<br /> � OWNER NAME: �� ,C)f�GS �-G� TENANT NAME(If Commercial): �'�Y1'���C% ���r�
<br /> OWNER MAILING ADDRESS: srR�'r l� 7�� G��i���� � �� /
<br /> CIIY �1/�.-��-L-� / / STATE µs� ZIP � ��T
<br /> OWNERPHONE: ���� S�?"`��-�l � OWNEREMAIL: ��1�lQ ` �m�° �-��
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<br /> CONTRACTOR NAME: ����'q�'K ���n����=S �NC,
<br /> CONTRACTOR ADDRESS: STREET �M ��. �e� �C 2'r S`� / ��
<br /> CITY G�`"�KC V ���vv� STATE �J� " ZIP ���
<br /> CONTRACTOR PHON �v�5 C��(�' ��� CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): CS��D'�FI��, � CITY flF EVERETT BUSINESS LIC.�#(REQUIRED): �/ ,
<br /> PRIMARY GONTACT:� �OWNERHM M,CIY+CONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: . � � (
<br /> /�u�.� �GL CONTACT EMAIL:
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<br /> AGREEMENT.�The undersigned applicant agrees to comply with af!provisions of the Evereft Municipal Code Tttle City of Everett Official Use Only
<br /> 94 Vl/ater and Seweror such other rules and regulations now existing or which may be established from time to FEE �l
<br /> time.The applicant further agrees,as a condifion precedent fo receiving service fhat the utilities division shail have ,
<br /> the righf at any time,without notice,to shut off or turn on the water supply forrepairs,construction,and
<br /> nonpayment of charges or for any otherreasonable cause.I am the owner,or!am authorized by the owner of this
<br /> properfy fo perf the work for w a lication is made,and!comply with th State Contractors Law 18.27 pERMIT# //�� ///���
<br /> RCWa 9 o0A .4 � �� � � �� ts�e �/Vl
<br /> 6 l �
<br /> Owne uthorized Ag nt Signat e Dat (Revised 10/92/2095J
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