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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@everettwa.gov � www.everettwa.gov/permits
<br /> _ . PROJEC'i' SI'i'E IId�ORMA'TION
<br /> _ —�
<br /> PROJECT ADDfZESS: �� c�`j i/'tV'.�� `/�'
<br /> IF APPLICABLE: ❑OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT#
<br /> BUILDING TYPE: ��R-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? �O ❑YES, FROM TO
<br /> UTILITY APPLIC,ATION IIdFORMATION
<br /> _ _ _
<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 /> CI SIDE SEWER RECONNECTlON ❑ COMMERCIAL
<br /> MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE: (circle desired size)
<br /> ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR ❑ DOMESTIC: 3I4", 1", 2", OTHER:
<br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ 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. F/LL OUT REVERSE SIDE OF THIS FORM.
<br /> ` ' ' ` CONTACT INFORMATION
<br /> OWNER NAME: �'�C��� �u-�c� TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: sraEer
<br /> CITY STATE Z�P
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<br /> OWNER PHONE: � ) __ `/ O .�' _ �O OWNER EMAIL: �`, .���O� '` d1�a��I d C�C v�.�
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<br /> �.�.�„.�.�, �__,.,.., ....,__ .,.,,, .�.,_,...__ ,.._,..... ,.., _. ..
<br /> CONTRACTOR NAME: `�C� ���, r • �`� . �'�/�� �-
<br /> CONTRACTOR ADDRESS: srRee-r �L��' �.�� � `7 "�
<br /> � � ��,,
<br /> CIT1' �� ��� �� STATE ZIP
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<br /> CONTRACTOR PHONE: �'�r-�`7 "`� '" �� CONTRACT�R EMAIL: , � � �YIQ ' �1��=,�-S��C_- + c r L6
<br /> ' _
<br /> CONTRACTOR LIC.#(REc�UIRED): � b 4��N'U ���c�� , CITY OF EVERETT BUSINESS LIC.#(REQUIRED): (� � , �
<br /> PRIMARYNCONTACT:` ❑OWNER ONTRACTOR ❑ OTHER(Please Specify)
<br /> CONTACT NAME: , CONTACT PHONE: c�U �� ���J - ���;�
<br /> � .V� ' U\��i U\�J'���� CONTACT EMAIL: �,-�nn � �,� . ���, Sti C. c 0�(I i C�CD 1M
<br /> AGREEMENT.'The undersigned applicant agrees to comply with all provisions of the Evereit Municipal Code Title City of Everett Offcial Use Only
<br /> 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to FEE
<br /> time. The applicant furthe�agrees, as a condition precedent to receiving service that the utilities division shall have
<br /> the right at any time,without notice,to shut off or furn on the wafer supp/y for repairs,construcfion,and
<br /> nonpayment charges or for any otherreaso le cause. am the owner,or I am authorized by the ownar of this
<br /> property per orm fhe work for w�app/ic i is made,and I comply with the State Confracfors Law 18.27 PERMIT#
<br /> RCW d 29 200A WAC. � � � � � jl�`�
<br /> (J i i��� � � �— � �� �
<br /> Owner uthorized Agent Signature Date (Revised 90/1712015)
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