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�� ATE / SEviEl. UTILITY 4 . *LIC*TION
<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? I,-
<br /> PROJECT ADDRESS: 'S8 Z co%' ,.,-)A 1b{. "£\reArt.Fs vJc 4 7' elg203
<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 ❑INDUSTRIAL
<br /> CHANGE OF USE? 0 NO ❑YES, FROM TO
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<br /> UTILITY APPLICATION INFORMATION'
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> --ti SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION
<br /> 0 SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY
<br /> KNEW SIDE SEWER INSTALLATION e ►Q'&No o'f5'\-- SERVICE/METER USE:
<br /> ❑ INSTALL BACKWATER VALVE(outside the building) 0 SFR
<br /> ❑ SIDE SEWER CAP-OFF 0 MULTI-FAMILY-#OF UMTS:
<br /> ❑ SIDE SEWER RECONNECTION 0 COMMERCIAL
<br /> MULTIPLE DOMESTIC WATER SERVICES REQUEST • WATER SERVICE TYPE I 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.
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<br /> CONTACT INFORMATION.
<br /> OWNER NAME: C, Y\C 6 Y-\t ) TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET cjp2. cyb o r,
<br /> CITY fAQjY eP� STATE t D Cot 9`g203
<br /> OWNER PHONE: 2._G 3- (pcb{ - (�li OWNER EMAIL: �'C.�t t e5@ cstntxi Corm
<br /> CONTRACTOR NAME:YY 6Q.i.�CX c-(�el'\C\\•y
<br /> CONTRACTOR ADDRESS: STREET 2,Q.3 of 3C� 13t,J Li 9� ,•� p Qr n
<br /> CITY Wt�IOV� J STATE Vll01 ZIP l U V
<br /> CONTRACTOR PHONE: 2,0(0 $''96- 1 LA $' CONTRACTOR EMAIL: e Stet (- .r ev k, ca -i
<br /> CONTRACTOR LIG,#(REQUIRED): Se„ae,,C V lko NQS CITY OF EVERETT BUSINESS LIC.#(REQUIRED):
<br /> .,...-, ,. .,....k,,,.t...aa. ,. ..m ._.,.,,«.._,.,.,......H.,,.•.,,.�...., .,.__,s...,�,..v,�.. -... -..-i,,...-.---- _ ,--..—.,�,--------,PRIMARY
<br /> ..,.. ,..M...,.. .PRIMARY CONTACT: 0 OWNER 'i-CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: 4 23 (. ` 7 73 3 r33
<br /> (kb\D '& CONTACT EMAIL: a-0 o , 59„),,,,c-t sonct L, .e-o s-'1
<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 maybe established from time to FEE
<br /> time. The applicant further agrees, as a condition precedent to receiving service that the utilities division shall have qn
<br /> the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and V''' 'nonpayment of charges or fo •ny.ther reasonable cause.I am the owner,or I am authorized by the owner of this ✓��w� '-
<br /> property t.perform the wor 11-w ich application is made,and I comply with the State Contractors Law 18.27 PERMIT#
<br /> RCW and 1,6.200A, AC I 6, r
<br /> Owner/• i ori ed Age t Signature Date (Revised 10/12/2095)
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