|
147.77 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.' j?A' S'w UV N- .
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? 2L1 ❑YES, FROM TO
<br /> UTILITY APPLICATION INFORMATION
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> 7 SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION
<br /> ❑ SIDE SEWER ALTERATION 0 COMPLETE SERVICE ❑METER ONLY
<br /> ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE:
<br /> O INSTALL BACKWATER VALVE(outside the building) ❑SFR
<br /> ❑ SIDE SEWER CAP-OFF 0 MULTI-FAMILY-#OF UNITS:
<br /> ❑ SIDE SEWER RECONNECTION ❑COMMERCIAL
<br /> MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE: (circle desired size)
<br /> ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR ❑ DOMESTIC: 3/4", 1", 2", OTHER:
<br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. 0 IRRIGATION: 3/4", 1", 2", OTHER:
<br /> ❑ 1 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: J &V M/ VI ` 1 i A.I TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET`)' Ot,/O i J� (/'�`�1. ^�,
<br /> CITY 1 `4 STATE \AM ZIPq (715
<br /> OWNER PHONE: , (t� �A OWNER EMAIL:
<br /> CONTRACTORNAME: _y.,..,.....,.��V 1 �.�,P 4"'�IY'�� .,.,....,.._�..M�.,, ,,._...-._.. .�...,...�....._ .....,.......,..._.. ..,�........................�.... u�.,, ..,,...,,�_....�._�.....,__ .
<br /> CONTRACTOR ADDRESS: STREET ytt I V ah, a •
<br /> "iYV � i I `�
<br /> CITY STATE wa • ZIP ',Sieb
<br /> CONTRACTOR PHONE:Uoif2A e' DOA CO TRACTOR EMAIL:alk,OWM it tt,, l I V1 w/1 O • OW _
<br /> CONTRACTOR LIC.#REQUIRED: 4111 CITY OF EVERETT BUSIN; LIC.#(REQUIRED); o5-155-(41
<br /> PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR ❑ OTHER(Please Specify)
<br /> CONTACT NAME: • CONTACT PHONE: (I.i)of 2'J--61921
<br /> r � �`1 Iv\,Y�V V CONTACT EMAIL: /A I[�ij I c �O I �VLI • -� m
<br /> AGREEMENT.The undersigned applicant agrees to comply with all provisions of the Everett Municipal Qode 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 FEE ti
<br /> time.The applicant further agrees, a con.]',n precedent to receiving service that the utilities division shall have ,the right at any ' e,w' . t notic to shut off o turn on the water supply for repairs,construction,and 1► .��nonpayment. ch-r•-s or or an other reasona,le cause.I am the owner,or l am authorized by the owner of this " 4
<br /> property top- or he wo` . hich applicato is made,and I comply with the State Contractors Law 18.27 PERMIT#
<br /> RCW and 29:200 k I C . / / r_��J 0dwner/Authoriz•4.gent Signature Date (Revised 10/12/2015)/
<br />
|