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WATER I SE SER UTILITY APPUUCCXT ON
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT, WA 98201
<br /> (P)425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits
<br /> PROJECT SITE INFORMATION
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<br /> PROJECT ADDRESS: 14 1c s2/4' S( t �j�
<br /> IF APPLICABLE: ❑ OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: ,$SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL DINDUSTRIAL
<br /> CHANGE OF USE? ANO ❑YES, FROM TO
<br /> 1
<br /> UTILITY APPLICATION INFORMATION
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> ❑ SIDE SEWER REPAIR 0 /'' Sa -e'( ❑ NEW WATER SERVICE INSTALLATION
<br /> A SIDE SEWER ALTERATION OerP776 0 COMPLETE SERVICE 0 METER ONLY
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<br /> ❑ NEW SIDE SEWER INSTALLATION Pry('47) SERVICE/METER USE:
<br /> ❑ INSTALL BACKWATER VALVE(outside the building) ❑ SFR
<br /> ❑ SIDE SEWER CAP-OFF I 0-01 2-, 0 MULTI-FAMILY-#OF UNITS:
<br /> ❑ SIDE SEWER RECONNECTION (ti 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. ❑ 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 ❑ DOMESTIC/FIRE COMBO: 1", 2", OTHER:
<br /> SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM.
<br /> CONTACT INFORMATION
<br /> OWNER NAME: I-4-/Act_.,t NI t>. \L(-tP"I1 A1.At- TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET
<br /> y�‘��J< �C)S( S LOA-
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<br /> -\ / r CITY C-- 16-I..-1. / STATE `.Oli-} ZIP GICej
<br /> OWNER PHONE: '_ V OWNER EMAIL:i/1' LS Ll 1< t1 Lei (.arkce,)i C 1,1'' ._..,.. __..
<br /> CONTRACTOR NAME: ` C.t ie_A✓ Zl__) I J t1 E,J�5 C>L- 5-CJ.Ti� L1 -t ..(_
<br /> CONTRACTOR ADDRESS: STREET j ‘ 1 `jJ�'��, (�V e6. -o ) ,-5.1--,
<br /> CITY 17---1- -LA to `-E-At 1 STATE ZIP '7 27
<br /> CONTRACTOR PHONE: 'J oO ft® CJot� CONTRACTOR EMAIL: t (j TYDC.re,eiL<.. ...v l(,4.0t'VI
<br /> >> ,- CITY OF EVERETT LIC.#(REQUIRED):c-714}'I
<br /> CONTRACTOR LIC.#(REc1UIRF<D). ,�.(��yL�{ '`���, �,{� -1'r It(-s
<br /> PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 'OTHER(Please Specify) I7f✓6 (/ 4al1-1--
<br /> CONTACT NAME: CONTACT PHONE: zexe, _94•1Z- 1..k9 Z,
<br /> -62.., -() i\Nµ CONTACT EMAIL: �iQ. � 6G,,,,,)NS-�,0CJ{(j�Jj'e.Lj w2_
<br /> AGREEMENT.'The undersigned applicant agrees to comply with all provisions of the Everett Municipal` !Code Title City of Evere7�Ofcciaall 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 /y � 6.
<br /> the right at anytime,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 tke work fo ' ich applicatio ' made,and I comply with the State Contractors Law 18.27 PERMIT#
<br /> RCW and 296.200A 4 / U t(? is 6-04---)---)
<br /> Owner/Authorized Agen Signature Date (Revised 10/12/2015)
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