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, -v---4' WA E ISE\ ER UTILITY APPLICATION^''",x CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT, WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857 1 (E)everetteps@everettwa.gov l www.everettwa.gov/permits
<br /> - • • • O.*OJECT SATE INFO, MATSOk .
<br /> - Y I
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<br /> PROJECT ADDRESS: �f ice /, , ^�� ���0:2-
<br /> � .. -
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA /I SF 0 LOT# r
<br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR ATTACHED �6ULEX ❑MULTI-FAMILY#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? 0 NO 0 YES, FROM TO
<br /> UTILITY APPLQCATb r' INFORMATION
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> CieSIDE SEWER REPAIR ❑NEW WATER SERVICE INSTALLATION
<br /> ❑SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER O
<br /> ‘:",) ,
<br /> ❑NEW SIDE SEWER INSTALLATION SERVICE/METER USE:
<br /> trINSTALL 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 /> 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 /> ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER 0 FIRE: 1", 2", 4", 6", 8", OTHER:
<br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER
<br /> 0 DOMESTIC/FIRE COMBO: 1", 2", OTHER:
<br /> SINGLE OWNERSHIP.FILL OUT REVERSE SIDE OF THIS FORM,
<br /> CONTACT INFORMATION..
<br /> OWNER NAME: Q 4/..404J (TV the/& TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: sTasEr /2S £r— LJ ( 41 9��
<br /> ., • ... c y SP.Sy7ei + .2 . .. STATE ZIP Ti
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<br /> OWNER PHONE_ .2-0 64 �OO g% OWNER EMAIL: c - (a/644a ! 4 „.,.......,,..----
<br /> CONTRACTOR
<br /> . .�,... 1r. „ .., w
<br /> a
<br /> CONTRACTOR NAME: M- ' (6W K6�-/
<br /> CONTRACTOR ADDRESS: STREET
<br /> •
<br /> MY STATE
<br /> ZIP
<br /> CONTRACTOR PHONE: CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED)m
<br /> PRIMARY CONTACT: (Jr1 WCONTRACTORSpecify)
<br /> NER 0 0 OTHER(Please Sp mYµ q~R4T U
<br /> CONTACT NAME: CONTACT PHONE: .24 6 4.1-..< d o 0 t(
<br /> ,;, e, t 611A4/10 1'e-' CONTACT EMAIL: kv,/40-(e.
<br /> C01.02 CV./06,2AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Coe 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.lam the owner,or 1 am authorized by the owner of this
<br /> properly to perform the work for which application is made,and!comply with the State Contractors Law 18.27 PERMIT#
<br /> RCWan• 200
<br /> '�'�'% 0,,,/,,/gU ( ga 3 -- 0
<br /> Owner/Aut orizetl Agent Signature ate (Revised 10/92/2095)
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