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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 /> _ PROJ�CY SI'TE 1NFOftM,�'TION _ _
<br /> PROJECT ADDRESS: ��1�`��� �,,�; - .� �-
<br /> IF APPLICABLE: ❑OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT#
<br /> BUILDING TYPE: t�SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY�#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? �N� ❑YES, FROM TO
<br /> UTILITY APPLICATION lNFOliMAT10N
<br /> SEWER(check all that apply) WATER(check all fhat 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 fhe 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. ❑ 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. FILL OUT REVERSE SIDE OF THIS FORM,
<br /> ` CONTACT. INFORMATION
<br /> OWNER NAME: �'i i✓� - ��l ��� - �� TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: sTReEr "��" /��!' "' ;-�.•� G, -�--
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<br /> CITY ���- �� STATE � ZIP � L� �
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<br /> OWNER PHONE: �� C.�Ci �� _ OWNER EMAIL:
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<br /> CONTRACTOR NAME: ,�; _. :-� I�� �� �"'` % �
<br /> CONTRACTOR ADDRESS: srREeT �S ` . / C �' �� J �
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<br /> STATE '� !V� /� ZIP � -��'
<br /> CONTRACTOR PHONE: 2U(�� `_ ' '� � �u CONTRACT�R EMAIL:
<br /> CONTRACTOR LIC,#(REQUIRED): � �1 C-�,:] ?/t%t U �� . CITY OF EVERETT BUSINESS LIC.#(REG2UIRED):C'�[ � � �
<br /> PRIMARY CONTACT: �0 OWNER .�CONTRACTOR ❑ OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: ��� �, � f �"=��
<br /> �'^� \L � `f ; CONTACT EtV(AIL:
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<br /> AGREEMENT.'The undersigned applicant agrees to comply with all provisions of fhe Everetf Municipal Code Tit/e City of Everetf Offcial Use Only
<br /> 94 Water and Sewer or such other rules and regulations now exisfing or which may be established from fime to FE�
<br /> time. The appircant further agrees, as a condition precedent to receiving service that fhe ufilities division shall have
<br /> the righf aE any time,without notice,to shuf off or turn on the water supp(y for repairs,construction,and
<br /> nonpayment of charges or for any otherreasonab/e cause.I am the owner,or l am authorized by the owne�of this
<br /> properfy to per the wo�k for which applicafion is made,and!comply with the Stafe Contracfors Law 98.27 PERMIT#
<br /> RCW and 6 OOA WAC.
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<br /> Owner/Authorized Agent Signature Date (Revised 90/12/2015)
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