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4477 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 I www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: 35-L7 z5-11- iti)A 9 (- -2,6)I <br /> � <br /> IF APPLICABLE: ❑ OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# <br /> BUILDING TYPE: SFR-DETACHED DSFR-ATTACHED ❑DULEX DMULTI-FAMILY-#OF UNITS: DCOMMERCIAL ❑INDUSTRIAL <br /> CHANGE OF USE? ;24NO 0 YES, FROM TO <br /> UTILITY APPLICATION INFORMATION <br /> SEWER(check all that apply) WATER(check all that apply) <br /> p 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 /> O 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 /> O I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR 0 DOMESTIC: 3/4", 1", 2", OTHER: <br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ 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 0 DOMESTIC/FIRE COMBO: 1", 2", OTHER: <br /> SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. <br /> I, CONTACT INFORMATION <br /> OWNER NAME: _rv� 1� SQ.‘ rr i) TENANT NAME(If Commercial): <br /> J <br /> OWNER MAILING ADDRESS: STREET 3 `l <br /> CITY tV C'v e STATE ��.:h - ZIP C/ <br /> OWNER PHONE: II OWNER EMAIL: <br /> CONTRACTOR NAME: ci � w` c-- <br /> CONTRACTOR <br /> CONTRACTOR ADDRESS: STREET Z �{C7 t %.:.) A\ L `�•� <br /> CITY > G._ - _ STATE l•� h_ ZIP CZSJ (U <br /> CONTRACTOR PHONE: Z •- C1 Z 11 11 CONTRACTOR EMAIL: <br /> CONTRACTOR LIC.#(REQUIRED): S y‘ 1---\k , )\-) (x Z k e CITY OF EVERETT BUSINESS LIC.#(REQUIRED): O3' c. <br /> PRIMARY CONTACT: ❑ OWNER CONTRACTOR 0 OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: L`(c LIL%, <br /> 'ACE_ ( C, , 'N S 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 <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 other reasonable cause.I am the owner,.or I am authorized by the owner of this <br /> property to perform the work for w ich app' tion is made,and I corn with the State Contractors Law 18.27 PERMIT# <br /> RCW and 296.200A WAC. U 2-02P <br /> Air <br /> OwneF/Authorized Agent Sign�fure Date (Revised 10/12/2015) , <br />