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Dec 02 19, 05:24 Holstad's PLUMBING INC. 3605889814 p.1
<br /> WATER I SEWER UTILITY APPLICATION
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<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT, WA 98201
<br /> (P)425-257-8810 f FAX 425-257-8857 1 (E) everetteps@everettwa.gov E www.everettwagovlpermits
<br /> SITE INFORMATION
<br /> PROJECT ADDRESS: �� E o rn PROJECT lr� y M N
<br /> IF APPLICABLE: ❑ OUTSIDE CITY LIMITS Ll BUILDING AREA —L ani�l
<br /> ,,� SF ❑ LOT#
<br /> BUILDING TYPE; X-ISFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: )COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? iv0 ❑YES, FROM
<br /> TO
<br /> UTILITY APPLICATION INFORMATION
<br /> •
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> J�SIDE SEWER REPAIR ❑NEW WATER SERVICE INSTALLATION
<br /> ❑ SIDE SEWER ALTERATION ❑COMPLETE SERVICE 0 METER ONLY
<br /> ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE:
<br /> ❑ INSTALL BACKWATER VALVE(outside the building) ❑SFR
<br /> ❑SIDE SEWER CAP-OFF ❑MULTI-FAMILY-#OF UNITS:
<br /> ❑SIDE SEWER RECONNECTION ❑COMMERCIAL
<br /> MULTIPLE DOMESTIC WATER SERVICES REQUEST
<br /> WATER SERVICE TYPE/SIZE:(circle desired size)
<br /> 0 I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR El DOMESTIC:
<br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. 3/4", 1", 2", OTHER:
<br /> ❑ IRRIGATION: 3/4", 1", 2", OTHER:
<br /> ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑FIRE: 1", 2", 4",
<br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER 1 6 OTHER:
<br /> SINGLE OWNERSHIP_FILL OUT REVERSE SIDE OF THIS FORM. ❑ DOMESTIC/FIRE COMBO: 1", 2" OTHER:
<br /> a
<br /> CONTACT INFORMATION
<br /> OWNER NAME: S U.S G th S�L�r TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET 2�a 1 e . C rel.r _Q
<br /> G'. ,�j��(C��l\ De Q
<br /> CRk,Y �o STATE as, ZIP q ()_'&
<br /> OWNER PHONE:.3 k::1 q 69 a3 q if
<br /> (OWNER EMAIL:
<br /> CONTRACTOR NAME; Hav,A,St&c_t p/0„1,14._._61, yk
<br /> CONTRACTOR ADDRESS: STREET f,E), 3e.,,x 5—‘, ,.,, k---
<br /> •
<br /> cur E err STATE r t ZIP i 7:).-- 'PG
<br /> CONTRACTOR PHONE:clag 4, 4/3/ !CONTRACTOR EMAIL:Ito f x�st,t 64
<br /> 5rt4 uw ]i V1 ey,,ri toy'.CO
<br /> CONTRACTOR TLIC.#(REQUIRED): if-1 /04 Y P.40 . '.N 9 !CITY OF EVERETT BUSINESS LIC.#(RL UIRED)>At)w ,N ^
<br /> PRIMARY CONTACT: El OWNER WCONTRACTOR ❑OTHER(Please Specify) r '
<br /> CONTACT NAME: CONTACT PHONE: t
<br /> 40 «s a3 Sc13 c*
<br /> 1�,r' CONTACT EMAIL:
<br /> AGREEMENT'The undersigned a agrees to comply with all provisions of the Everett Municipal Code Title
<br /> 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to City of Everett Official Use Only
<br /> tiros.The applicant further agrees,ES a condition precedent to receiving service that the utilities division shall have IFEE
<br /> t'�`
<br /> the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and \{� /J,D.0.g,
<br /> n.onpaymentofcharges orfor any other reasonable cause.lamthe owner,or I am authorized by the owner of this
<br /> �Wff" /
<br /> property to perform the work for which appllcetion is made,and!comply with the State Contractors Law 18.27
<br /> RCW and 295.200A WAC. PER�IT Q D
<br /> OwnerlAuthorizedAg tSlgnat Date
<br /> I .1: Cp2- /1--.O79-- / 9' U 12,�(Revised 10/12/2015)
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