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<br /> ' I,,, TER I SE !Y' `E« UTILITY AP,L1 LUCAT9O.
<br /> r . . -_ CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT,WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857 I (E) everetteps@everettwa.gov I www.everettwa.gov/permits
<br /> PROJECT SITE INFORMATION
<br /> .7C PROJECT ADDRESS: / Q..-' J/i./ �i�,c., e
<br /> iF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL CI INDUSTRIAL
<br /> CHANGE OF USE? 0 NO 0 YES, FROM TO
<br /> UTILITY APPLICATION INFORMATION
<br /> SEWERch
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION
<br /> ❑ SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY
<br /> ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE:
<br /> ❑ INSTALL BACKWATER VALVE(outside the building) 0 SFR
<br /> ❑SIDE SEWER CAP-OFF 0 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 0 DOMESTIC: 3/4", 1", 2", OTHER:
<br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. 0 IRRIGATION: 3/4", 1", 2", OTHER: '
<br /> ❑'1 AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER 0 FIRE: 1", 2", 4", 6", 8", OTHER:
<br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER 0 DOMESTIC/FIRE COMBO: 1", 2", OTHER:
<br /> SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM.
<br /> CONTACT INFORMATION
<br /> OWNER NAME: C'a..1-4/ "e/i 0.---k TENANT NA E(if Commercial):
<br /> OWNER MAILING ADDRESS: STREET /� 0i- !''/Y-.)."1.4-- v�'V v/'e
<br /> CITY LL—ii e ‘--e
<br /> STATE 1...X., ZIP / d!„ ...47/
<br /> OWNER PHONE: OWNER EMAIL:
<br /> o ,,x .�.� w. ... .V..,w.,.6,4". ...N.. ,,a.,,,,,..M..," _,,,..,.,.:,.,,...W,,. ..,.......•,,,,,,,,,,,,,,1...,,sy w„ .1,4..��w,N,.d,,...A V.., ,.,.,..,4..., ww..•w... ..Maar
<br /> CONTRACTOR NAME: VJ .,14 GYe j T /0/;�` 6 -.5 ,c
<br /> CONTRACTOR ADDRESS: STREET 2 7.1 .-7/ Cf e...._., /4/...„,%�- l /9 /f
<br /> CITY G � C STATE �-z./ ZIP Q'6i l/G//�
<br /> CONTRACTOR PHONE: CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): CiTY OF EVERETT BUSINESS LIC.#(REQUIRED):
<br /> PRIMARY CONTACT: EI`OWNER m❑CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE:
<br /> CONTACT EMAIL:
<br /> AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title City of Everett Official Use Only
<br /> 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to FEE F�
<br /> time.The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have
<br /> c>.
<br /> the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and �O.v
<br /> nonpayment of charges or for any other reasonable cause.I am the owner,ort am authorized by the owner of this _
<br /> property to perform the work for which applicationxjs ma e;`and c.mply with the State Contractors Law 18.27 PERMIT#
<br /> 'cRCW and 296,200A WAC- ,
<br /> Owner/Authorized Agent Signature IOW Date (Revised 10/12/2015)
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