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<br /> CITY OF EVERETT PERMII" 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 /> PR.OJ���' SI�'l� �f���13�11i�'�'O�i`�
<br /> PROJECT ADDRESS: � O �Z { �
<br /> IF APPLICABLE: ❑ OUTSID CITY LIMITS ❑ BUILQING AREA SF ❑ LOT#
<br /> BUILDING TYPE: ❑S R-DET CHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERClAL ❑INDUSTRIAL
<br /> CHANGE OF USE? ❑NO ❑YES, FROM TO
<br /> U7'1L.ITl( AP�LICf�'Y°IORI Ifd�ORMAI'10@d
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION
<br /> ❑ IDE SEWERALTERATION ❑ 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/51ZE: (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 /> ❑ 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: • cQ�� ���" I,C�%V S TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET G'V�
<br /> CITY � STATE ZIP �� ���
<br /> OWNER PHON : �� (v�l�3 OWNER EMAIL:
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<br /> CONTRACTOR NAME: � �E,'��7' � ,Tt e� �'�� �`1 �` �� ��`�, �
<br /> CONTRACTOR ADDRESS: sTREer
<br /> CITY STATE ZIP
<br /> CONTRACTOR PHONE: CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): �l �, CITY OF EVERETT BUSINESS LIC #(REQUIRED): �Q
<br /> .:..._..._-,._,...____- . ....__..��.�..,._ .. _n,._,...�. __ �..,._,. .
<br /> PRiMARY CONTACT: ❑OWNER ❑CONTRACTOR ❑ OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE:
<br /> COFITACT EMAIL:
<br /> AGREEMENT.'The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code i"ifle City of Everett O�cial Use Only
<br /> 94 Vl/ater and Sewer orsuch ofher rules and regulations now existing or which may be established from time to FEE
<br /> time. The applicant further agrees, as a condition precedent to receiving service that tl�e utilities division shal!have JC��
<br /> the right at any time,withouf notice,to shut otf or furn on the wafer supply forrepairs,construction,and
<br /> nonpayment of cl�arges or for any other reasonable cause.l am tlie owner,or I am authorized by the owner of this
<br /> properly to perform the work for which appiication is made,and I comply�vith the Sfafe Contractors Law 18.27 PERMIT#
<br /> RCW and 296.200 WAC. f �
<br /> ,(��� 1 A�-�� z/ zl � �
<br /> Owner/Authorized Agent Signafure Date (Revised 90/17J2095)
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