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ITER I SEWER UT UUTYA PPU I CATIO
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> - 3200 CEDAR STREET, EVERETT,WA 98201
<br /> (P)425-257-8810 1 FAX 425-257-8857 I (E) everetteps@everettwa.gov 1 www.everettwa.govlpermits
<br /> .i....
<br /> H41.?/.• -, PROJECT SITE INFORMATION t.,-, -� , , ` - _ ,.
<br /> PROJECT ADDRESS; zc)A
<br /> `_ �, _a '' e . _ 1� �
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS �■ 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 0 YES, FROM TO
<br /> UTILITY APPLICATION INFORMATION ,
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> X SIDE SEWER REPAIR',V(Q.,-Zh Or- 0 NEW WATER SERVICE INSTALLATION
<br /> :: ," SEI, ' • `.= e 0 COMPLETE SERVICE 0 METER ONLY
<br /> •
<br /> (' & 'SE 1 1 • `TION 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 /> ❑.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: 'fix ` -jIgo
<br /> _ TENANT N ME(If Commercial);
<br /> OWNER MAILING ADDRESS: STREET S //Co, le47 r
<br /> cmr� e
<br /> STATE �,. ZIP qZ2 0 1
<br /> OWNER PHON f.Z., 5 86( OWNER EMAIL:
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<br /> CONTRACTOR to Deo C 0
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<br /> CONTRACTOR ADDRESS: STREET , 6'1' St--
<br /> CITY
<br /> tCITY Ptitt- STATE / ZIP eigOzC
<br /> CONTRACTOR PHONE: l itae) a t CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED):gEitc()P CITY OF EVERETT BUSINESS LIC.
<br /> MA #(REQUIRED)rY-f S
<br /> 'PRIMARY'
<br /> CONTACT: W
<br /> ❑ONER 6-CONTRACTOR—
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<br /> CONTRACTOR -OTHER(Please Specify) ` l)Lt'II;6
<br /> CONTACT NAME: CONTACT PHONE: e0,
<br /> /- F .6 1/1 A CONTACT EMAIL:b4& i ti 069 65,
<br /> ytt c4.1 L cCcn
<br /> AGREEMENT.The undersigned applicant agrees to comply with all provisions of the Everett M nicipal Code Title City o rett 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 anytime,without notice,to shut off or turn on the water supply for repairs,construction,and 1 'e ,
<br /> nonpayment of ch- 'es or for y other reasonable cause.I am the owner,or I am authorized by the owner of this
<br /> property to pa,/the wo'�r w 'ch applicati. is made,and I comply with the State Contractors Law 18.27 PERMIT#
<br /> RCWend s.. 00A MO U Da-0414
<br /> l'O()1(
<br /> Ow •r/Authorized Agent Signature ` Date (Revised 10/12/2015)
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