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477 WATER / SEWER UTILITY APPLICATION <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 www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: Ci--)--C) k. \i'Dc4 ,� L\dI <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? ❑ NO 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 /> 0 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 /> 0 SIDE SEWER CAP-OFF 0 MULTI-FAMILY-#OF UNITS: <br /> 0 SIDE SEWER RECONNECTION 0 COMMERCIAL <br /> MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE: (circle desired size) <br /> 0 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 /> 0 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/FIREICOMBO: "�„„ 1", 2", OTHER: <br /> SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. 1f ,��llkI.,'E,"t r/1.9��L ✓ TU /Mfv t�GI GI , <br /> CONTACT INFORMATION) <br /> OWNER NAME: TENANT NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET <br /> CITY STATE ZIP <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR NAME: COG l C1d( t 9 01 cr�3' C <br /> CONTRACTOR ADDRESS: STREET p ti 3�J x <br /> CITY CcIC (5 VY\ S r ) STATE LAJ <br /> t / j �tOl <br /> CONTRACTOR PHONE:��.�j-- �Dj�� - � � CONTRACTOR EMAIL: 6 lG{d. , C 1 p►rC I vi <br /> CONTRACTOR LIC.#(REQUIRED)C6 1�1�1��ti � CITY OF EVERETT BUSINESS LIC.#(REQUIRED):0as-q----t t) <br /> PRIMARY CONTACT: 0 OWNER/ I CONTRACTOR 0 OTHER(Please Specify) - <br /> CONTACT NAME: CONTACT PHONE: L(4 R1- 1"""llel <br /> Cro h e U) e� CONTACT EMAIL: 5,5_0 to (�S P I C. CtO r` <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 /> 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 er reasonable cause.I am the owner,or I am authorized by the owner of this <br /> pro erform the work f which application is made,and I comply with the State Contractors Law 18.27 PERMIT# <br /> 'Nand 2 200A WAC. <br /> /4( 0- 11 c , U 0q-r):1 <br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015) <br />