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�V���'��3 � �C�1��3 ��QL�O��`( /�p[�I�O��`�n��
<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.everettwa.gov/permits
<br /> ��.o��c� �'�� r��o�n���-a��
<br /> PROJECT ADDRESS: �,(,l,� C:� .� '�, S�-V�� ��'' �� '
<br /> IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDWG AREA SF ❑ LOT#
<br /> BU(LDING TYPE: *�SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? '�N� ❑YES, FROM TO
<br /> U"�1�..17`l( APPL.ICA"T"IOA1 1Ia1F0l�IViA�'IOPd
<br /> SEWER(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 ❑ DOMESTIC: 3/4", 1", 2", OTHER:
<br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ IRR(GATION: 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.
<br /> CONTACT INFORMATION
<br /> OWNER NAME: �� • ,��� TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: sTREer �,�L�, � ''�.�.'L� %�. �'�
<br /> �?'V��� V � � ZIP �,
<br /> C��, STATE ��,1`��
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<br /> OWNER PHONE: '�j 1 C "(� � OWNER EMAIL:
<br /> ,,T��.�w�,,.,, ,,.._,� ... ..,..�.: .. ,.... _.�,_�.. „. ,.,..�,.,.. �,., , ,
<br /> CONTRACTOR NAME: '� j
<br /> CONTRACTOR ADDRESS: sTReEr
<br /> CIN STATE Z�P
<br /> CONTRACTOR PHONE: CONTRACTOR EMAIL:
<br /> CONTRACT'OR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC #(REQUIRED):
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<br /> PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR ❑ OTHER(Please Specify)
<br /> GONTACT NAME: CONTACT PHONE:
<br /> CONTACT EMAIL:
<br /> AGREF_MENT.'The undersigned applicanf agrees to comply with all provisions of the Everett Municipal Code Title City of Evereff Offcial Use Only
<br /> 94 Water and Sewer or such ofher rules and regulations now existing or wl�ich may be esfablished from time to FEE O(�
<br /> time.The applicanf further agrees, as a condition precedent to receiving service that the utilities division shall have
<br /> the right af any time,without notice,to shut off or tum on the wafer supply forrepai�s,construction,and 30 ��
<br /> nonpayment of charges o�for any other reasonable cause.1 am tlie owner,or!am authorized by the owner of fhis
<br /> property to perform the wo�k for ap tion is made,and 1 comply with the State Confractors Law 98.27 PERMIT#
<br /> RCW and 296.200A WAC. LJ � '� O �' /, I
<br /> � �f ,� ���; U
<br /> wner/Aufhori 4�Signa �re Date (Revised 90/12/2095)
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