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ER. / SEWEID UTILITYPLICATION
<br /> s4► CITY OF EVERETT PERMIT SERVICES
<br /> r�
<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 /> PROSJ�Ci�SINEINFORAT
<br /> I®N
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<br /> PROJECT ADDRESS: VII 1 1 V 'r ` a
<br /> iF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDi G 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
<br /> UTILITY APPLICATION INFORMATION ::::;,7:::::..
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> ❑ SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION
<br /> ❑ SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY
<br /> •
<br /> ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE:
<br /> ❑ INSTALL BACKWATER VALVE(outside the building) 0 SFR
<br /> ISIDE SEWER CAP-OFF sieitft of V1( . 0 MULTI-FAMILY-#OF UNITS:
<br /> ❑ SIDE SEWER RECONNECTION VV 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 r-q
<br /> OWNER NAME: TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET
<br /> CITY STATE ZIP
<br /> OWNER PHONE:,,,_,,,,,,,„., ,•, -;.:----- _,, ,_______,,.,___,_,,,OWNER EMAIL:
<br /> CONTRACTOR NAME: F-'
<br /> CONTRACTOR ADORES • REET
<br /> CITY STATE ZIP
<br /> CONTRACTOR PHONE: CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(RE IRED
<br /> PRIMARY FCONTACT:� 0 OWNER �❑CONTRACTOR 0 OTHER(Please Specify) c
<br /> CONTACT NAME: CONTACT PHONE: ( l -451-1 %0
<br /> \(AeM„ V/I(', I Vatii
<br /> 171
<br /> 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 00
<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 I
<br /> nonpayment of charges or for any other reasonable cause.I am the owner,or!am authorized by the owner of this
<br /> property to perform the work for which application is made,and!comply with the State Contractors Law 18.27 PERMIT#
<br /> RCW and 296.200A WAC. U 1 igt01 -02-
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<br /> -02,
<br /> Owner/Authorized Agent Signature Date (Revised 10/1212015)
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