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a�E� r � ��� AF�uc,�T� �
<br /> GlTY t�F EVERETT PERMiT SERVIC�S
<br /> 32t10 CE�RR STREET, EVERET`T,Wl�98201
<br /> (P)425-257-881�3 ( FAX 425-257-885r� � {E)everetteps a�,?everettwa.gov� www.everetfi�a.gov/permits
<br /> P�t����T �aT� o�r��►���°ri��r
<br /> PROJECT ADDRESS: 1� i�Y . #'' �r� �A ��.,��`�
<br /> IF APPL.ICABLE: Cl Oi..lTSID�C17Y LI � BUILClING AREA 5F C�LO�#
<br /> BUlLDiNG tYPE: SFR-OETACHED �SFR-ATTACHED ❑DULEX ❑MULT{-FAMILY-#t7F UNITS: E�Ct}MMERCIAL ❑INdUSTRIAL
<br /> CHAtJGE OF tfSE? �a ❑YES. FROM TQ
<br /> UTILITY 14PP�.ICATIO�N IN�QRMATlON
<br /> SEWER(check a{t that aPP�Y) WATER(check alf thai aPPeY)
<br /> �,SI[7E SEWER REPAfR ❑hlEtN WATER SERViGE INSTALLATtON
<br /> C)SIDE SEWER ALTERATION ❑GfJMPLETE SERVICE 0 NfiETER t�NLY
<br /> �tdEW SIDE SEWER 1(�STALfATEON SERVICE!METER USE:
<br /> �iNSTAE.L BACKUVATER VALVE(outside the buifding) C7 SFR
<br /> �5I93�SEVYER CAP-OFF �PJIUL�!-��kA�iLY-#C7F UNITS:
<br /> �Sit1E SEtiNER RECUtdhiECT1t3N C�CO?vi1�EF€�C4AL
<br /> Mt9LTIPL�130MESTtC A�'ER S�FtViCES REQl3�ST WATEI�S�RVtGE'�YPE 1 S4ZE:(eirccte des(red size}
<br /> �},4Tv1 DECLINING MULTIPLE C?OMESTiC WATEF2 SERVIGES Ft�R CI DC}MESTI�C: 31d". 1", 2", OTHER:
<br /> MY MIJLTI-FAMI�Y DEVELC7PMENT UNDER SINGLE OWIUEFLSHlP. � kRRIGAT'It3N: 3/4", 1", 2", flTHEf2:
<br /> ❑I AM OPTlNG TQ INSTALI h�t1LTEPl.E Dt7MESTIC WATEFt CI FIRE: 1•, 2". 4", 6", 8", OTHER:
<br /> SERViCES FOR MY MULTI-FAMILY DEVELOPMENT UNi3EE2 ❑pp��STlCJFiRE COArt80: 1", 2", OTHER:
<br /> SINGLE OWNERStiiP.�ILL K?UT RL"-VERSE St�E 1�FTfflS FORM.
<br /> CON417"ACT IN�ORiMIA1t°I�N
<br /> OWNER NAME: � � �� ` �} , � ���'�t�'S�- TENAiVT NAME if Commercial :
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<br /> OiNNER MAIIING AaDRESS; � eET �'� C..� f� �� � �,��1,� �-'t.� '� -
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<br /> CfTY STAIE Z1P
<br /> OWN�R PH4NE: �`� 1' � �a 4"r . C3l+YNER EMAIl.: ����a���' ' ,. ..,.�`�..���,i'�t�,� t � �����ti..-
<br /> � .�+ " l.
<br /> Gi�NTRA�TCdR tdAME: �,� , � '� ' �"�� Y"��'� �'"'� -�-
<br /> C��TRA+CTOF2 A�L?F2ES5. sTrxesr �,� . , „�"�q � �" �°°
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<br /> CRl' �gf STATE � !�I i IP
<br /> cc���c�cTOR�HON�: B �� . ��� �. ��- � � � cc�N�r�c�-oR�na��: `����a�p�?���:°�"���i`� p,-�,�, - r��"� ������'�`��
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<br /> ,- t� �•, s��� ^� �rz'„�,� CITY O� RE1`t'6UStNESS LlC,t€(R�QU1Ft�D c � � �..:;
<br /> CONTRACT4R LIC.#{REQUtRE�:�4: V�d.% 4,,� �
<br /> PRiMARY CONTACI': ❑OUVtdER COM1lTRACTqR �OTHER(i'lease Spec'r#y}
<br /> CC�R3TACT WA�VIE: � CdNTACT PHC11dE: � °� , � � , - �`�'� '<-1
<br /> � �'' r�� ���������.� �crr�ra��T Er�}v�: ���;11�F�t'Yl �_-�',� ���F'��:a�-��� ���"�`�`�
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<br /> AGRE6�OENT. The undersigned applica't a es fo compty wrth aA provisinns ot the Everetf tviunicipa Cafe Titie t4 Water and Sewar or such othsr rules anu'regulatrons now
<br /> existing or which may 6e established from re ta tkrre. The applrcanY furfher agrees,as a condition precedent to receiving service thai the Ufrtrties div+sion sha1�have tha rrgh#at a»y
<br /> Gme,wilfiout notica,to shuf oB or tum on the wa[er s�pply for repeirs,cwistrucfion,and nonpayment of chat�ss ar for any othe�reasonable cause.1 am fhe owner,w 1 artr
<br /> aufhorrzed by the owner of ihis property to pertorm the work�or whrch appticatiarr is made,anU!camply with tho State Contraciors Law 78.27 RCW and 296.200A WAC.
<br /> r- ,..� Crty of Everett Offrcia!tJse Onty
<br /> F '. � F
<br /> � a s ; PERMIT
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<br /> Ow erlA rized Age»t at rs Csete (Revised�/23/2t196}
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