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047-7- W �R / SEWER UTILITY A -3LICATION
<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: ��S J e ,!fr:-,:' ... 7 ,.z o 4--
<br /> IF APPLICABLE: fL9 OUTSIDE CITY LIMITS 0 BUILDING AREA SF LI LOT#
<br /> BUILDING TYPE: ❑SFR-DETACHED G SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OFUNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? NO ❑YES, FROM TO
<br /> UTILITY APPLICATION INFORMATION
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> ❑ SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTAL ION
<br /> ❑ SIDE SEWER ALTERATION (� yOMPLETE SERVICE LY
<br /> n NEW SIDE SEWER INSTALLATION + �0.--t s�,SieM/f-vwv. SERV.IIxt METER USE:
<br /> ❑ INSTALL BACKWATER VALVE(outside the building) CSI SFR ))._0(:)01
<br /> 0 SIDE SEWER CAP-OFF �.4 Oui-af 0 MULTI-FAi. '-#OF i' ...
<br /> v'
<br /> ❑ SIDE SEWER RECONNECTION P\ r 0 COMMERCIAL
<br /> MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE- c, "E: (circle desired size)
<br /> ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR 0 DOMESTIC 1i". (7,-) 2", OTHER:
<br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. 0 IR'L,I4TION: 3/4', " 2", OTHER:
<br /> ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER UF-:;RE: 1", 2", 4", 6", " OTHER:
<br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER 0 DOMESTIC/FIRE COMBO: 1", 2", THER:
<br /> SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM,
<br /> —
<br /> CONTACT INFORMATION
<br /> OWNER NAME: '–.J -C rc-11' ' ';1 y TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET p. -) t 6 c T' / Cr
<br /> CITY �– V
<br /> STATE (.A., `1` ZIP re-2 6 ,6
<br /> OWNER PHONE: ( L S-- tj L 1- /,.. S OWNER EMAIL 1 J G? ii-7• /1 c ..}-,<J i 4_,,.' E` 7/U✓ t;.'. J.. a _... .
<br /> CONTRACTOR NAME: j) )j' /7 .(J- �"- %� e S
<br /> CONTRACTOR ADDRESS: /STREET f' c i3 X 7/
<br /> CITY 7---1-) STATE ( ,l ) ( ^ ZIP t(ril"--) J (
<br /> CONTRACTOR PHONE: .y vi..-4 CONTRACTOR EMAIL: S
<br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED):
<br /> PRIMARY CONTACT: ,IKI OWNER ❑CONTRACTOR ❑ OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: (' -) i- _ '( 2 2 - /,`,. J-7
<br /> S> r p- c_ ^,7 CONTACT EMAIL: I_. 1J ;,_r. ,„ _. , _ 'i � ,J
<br /> ,\ - . (- ,/' tn4: ,i, ( tL .:-c
<br /> AGREEMENT.The undersignederapplicant 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 maybe 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 y, ` a
<br /> the right at any time,without notice,to shut off or tum on the water supply for repairs,construction,and 0
<br /> �'1l tU/, °
<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 which application is made,and I comply with the State Contractors Law 18.27 PERMI ,#
<br /> RCW and 296.200 WAC. l/ e,/L u ' �J
<br /> ' o ,/ `161 -ND
<br /> D
<br /> Owner/Authorized Agent Signature _. Date (Revised 10/12/2015)
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