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"Illid:=A
<br /> VVI ;R / SEWER UTILITY P --ILICATION
<br /> 41A 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: /._ _ C)(EWA.) /9/',c /b k.�%/
<br /> IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDING AREA SF El LOT#
<br /> BUILDING TYPE: I'�'9FFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? VisNIO ❑YES, FROM TO
<br /> UTILITY APPLICATION INFORMATION
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> ❑ SIDE SEWER REPAIR )NEW WATER SERVICE INSTALLATION
<br /> ❑ SIDE SEWER ALTERATION ❑ COMPLETE SERVICE 0 METER ONLY
<br /> ^NEW SIDE SEWER INSTALLATION SERVICE/METER USE: To o ,: . . t,,„o, t0 ///l
<br /> ❑ INSTALL BACKWATER VALVE(outside the building) SFR
<br /> ❑ SIDE SEWER CAP-OFF ❑ 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 DOMESTIC: (Rir-lii72", 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 /> •
<br /> SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM.
<br /> CONTACT INFORMATION
<br /> OWNER NAME: IJV 5-,--,:/,,R C v54',!,.( ,,,,,,c.,7- - TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET ,^ 3.. 4 c /,,z .4 3 �] 7
<br /> �id-�Y sc/ LL<< CITY l.a,//,� STATE iC8�/ ( ZIP
<br /> OWNER PHONE: /--/2 .) 8 7 66 SY / OWNER EMAIL: iiI L7/</%Q/ ' IS () (.✓'/L ( VI.__.. .
<br /> CONTRACTOR NAME: A1,+'57-4-A, c u_52-04,4
<br /> ( / /A-' (
<br /> CONTRACTOR ADDRESS: STREET A 0 . £G/C [ A T 3 /
<br /> / -i�7'l`,YS U/L-L CITY STATE 'I�r//4- ZIP `7 E) 7c
<br /> CONTRACTOR PHONE: ^/ CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC #(REQUIRED):,C�(4A:C 9/2_) C Cj CITY OF EVERETT BUSINESS LIC.#(REQUIRED):533 3 G
<br /> •
<br /> PRIMARY CONTACT: ❑OWNER ilaQNTRACTOR ❑ OTHER(Please Specify)
<br /> CONTACT NAME: n L)i- CONTACT PHONE: t� f_ 6S., 7 - 5Y/
<br /> /� C)$T I 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
<br /> time. The applicant further agrees, as a condition precedent to receiving service that the utilities division shall have
<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.I am 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 296.200A WAC. ?-----,f--
<br /> r' L
<br /> ,;ate, �
<br /> L _ l ?
<br /> 0 ner/Authorized Agent Signature Date (Revised 10/12/2015)
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