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WWTER / SEWER
<br /> UTILITY tIPPLICATION
<br /> /1411-.4
<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: /. 03 /',C o%2.(h/, 6g-
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS ❑ BUILDING AREA S,000 " SF J2 LOT#
<br /> BUILDING TYPE: SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? .-NO 0 YES, FROM TO
<br /> UTILITY APPLICATION INFORMATION
<br /> SEWER(check all that apply) WATER (check all that apply)
<br /> ❑SIDE SEWER REPAIR PL.NEW WATER SERVICE INSTALLATION
<br /> ❑SIDE SEWER ALTERATION 0 COMPLETE SERVICE ,METER ONLY
<br /> Cg.NEW SIDE SEWER INSTALLATION SERVICE/METER USE:
<br /> ❑ 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 /> ❑ 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 /> ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER FI j 2", 4", 6", 8", OTHER:
<br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER zritDOMESTIC/FIRE COMBO: 0, 2', OTHER:
<br /> SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM.
<br /> CONTACT INFORMATION
<br /> OWNER NAME: 3vS77 i/ co5?U CJ,t,a2uc7/dam TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET ta.
<br /> 0. 'C,' /2<'3
<br /> /_/ /5rl./-.L.�- CITY (, if STATE 91502 70 ZIP
<br /> OWNER PHONE: 'i)3-',976-65/ OWNER EMAIL: e '(-)5TM-PooilE,05' -mot' (-l)/t'fTA-v✓[7D,Vc C— i},(G.
<br /> CONTRACTOR NAME: 6U�777,4\ CO,C7G -(
<br /> CONTRACTOR ADDRESS: STREET v , dGik / L/13
<br /> V [ '!• (ysL"j1/Z , CRY L,.e,/ STATE �C 7o ZIP
<br /> CONTRACTOR PHONE: 1L 2 19 7 -657 '/ CONTRACTOR EMAIL: 8L 1 f77 // co f7?)t--1Ca/U.512I V(7/0,/ /*A,
<br /> CONTRACTOR LIC.#(REQUIRED):A Q.5 (C )_S- C-7C CITY OF EVERETT BUSINESS LIC.#(REQUIRED):S]?63
<br /> PRIMARY CONTACT: ❑OWNER ckcONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: I c J -126 -6 SiS /
<br /> 19/1V1--8 0,(7 ,6 CONTACT EMAILA)q ccykei e0A,6,T/_0'ia./v01'' /W
<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 /> time. The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have FEE
<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 which application is made,and I comply with the State Contractors Law 18.27 PERMIT#
<br /> RCW a 96.200A WAG.
<br /> -z-.,CLS C, ! 3 -/// U
<br /> Owner/Authorized Agent Signature Date
<br /> (Revised 10/12/2015)
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