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e e' 'ATE / SEINEsq UTILE *PPLICATION
<br /> ;, 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 /> PROJECT ADDRESS: / 3 2S /41L asap J/
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS
<br /> 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: ❑,SFLi
<br /> R-DETACHED FR-A ❑
<br /> TTACHED ❑DULEX MULTI-FAMILY#OF UNITS: ❑COMMERCIAL DINDUSTRIAL
<br /> CHANGE OF USE? fO 0 YES, FROM TO
<br /> UTILITY APPLICATION INFORMATION
<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 0 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 /> ❑ I 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: S 61-evm--1 7-4/t '4 TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET , 3 '2344 a.} 01./(
<br /> O)
<br /> CITY 6-i.e./Leg-I-- /�,`/ STATE 1�V n ZIP
<br /> OWNER PHONE: 47/2-5. 4: 2 3 '19515- OWNER EMAIL:
<br /> CONTRACTOR NAME: ����` `G S
<br /> CONTRACTOR ADDRESS: STREET 2.. /"- �i (/�4 � � e-,-
<br /> CITY S-7,1-0 b 47j /4- _ v STATE ZIP L'6'2%�r e?
<br /> CONTRACTOR PHONE: e-(2-45.- 0/2 3 4,/ CONTRACTOR EMAIL: jp 5e54- / iecf/v0°J J.CO241
<br /> CONTRACTOR LIC.#(REQUIRED): 304 '(; ST)IC T CITY OF EVERETT BUSINESS LIC.#(REQUIRED):
<br /> �,�:.,—::,,��.u:.�...,::9.�..__.,.�-K.v._x_a��.:�,_,-�...... ,:r.- ��. ._:,---...:_:,:�.-_,-:-_,x.:..,�_. , .r_._-,..,,..:,_,._�:,...._.. . :.,rw_,...�:-r.- .....: .,.,._.:..::.-.F...vw__x:..,_::_..-.-3.�,v,_.,,� . a_, :.u-
<br /> PRIMARY CONTACT: I dWNER ►l. 0 RACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: 412-5" 'l Z.3 (.
<br /> afra fol_erm CONTACT EMAIL: ia..0 StP,v✓/ / -71r J Cdgri
<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
<br /> time.The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have FEE 0°
<br /> the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and
<br /> nonpayment of charges or for any other reasonable cause.lam the owner,or I am authorized by the owner of this
<br /> property to perform the work for which application is made,and I comply with the State Contractors Law 18.27 PERMIT#
<br /> RCW and •-. • WAC.
<br /> _...-. 9 3 7,,e2!S U j ta, of
<br /> Owner/Authorized .gent ;.•. . - Date (Revised 10/12/2015)
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