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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/perrnits
<br /> PROJECT SITE INFORMATION
<br /> PROJECT ADDRESS: 22 1 p Y i\ \V d .
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA. SF ❑ LOT#
<br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑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 /> lI SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION
<br /> ❑SIDE SEWER ALTERATION 0 COMPLETE SERVICE ❑METER ONLY
<br /> 0 NEW SIDE SEWER INSTALLATION SERVICE/METER USE:
<br /> O INSTALL BACKWATER VALVE(outside the building) 0 SFR
<br /> ❑SIDE SEWER CAP-OFF 0 MULTI-FAMILY-#OF UNITS:
<br /> 0 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 ❑ 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 0 FIRE: 1 2", 4", 6", 8", OTHER:
<br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER 0 DOMESTIC/FIRE COMBO: 1", 2", OTHER:
<br /> SINGLE OWNERSHIP.FILL OUT REVERSE SIDE OF THIS FORM.
<br /> CONTACT INFORMATION
<br /> OWNER NAME: gg,V n y -coo( V� I TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET `l�2(O f I A1 ) `vak •
<br /> CITY u l V -irSTATE V ZIP 1 — "' 1
<br /> OWNER PHONE: iiAA r r���� OWNER EMAIL:
<br /> CONTRACTOR NAME: `...., .,N..�1 � ..,�ff 4 YVI � . ,. ....., .u„, , ,.�..,,,.... .,,•.�..��,. .... ..��....,.�,_,
<br /> CONTRACTOR ADDRESS: STREET �' Y �� V h s •
<br /> "�V
<br /> CInY �AJ STATE WA • /ZZIIP ,�y�,
<br /> CONTRACTOR PHONE:Obi)�V®12� CO TRACTOR EMAIL: 41, b� t, l . 1 O Yf 1{/4 I it t 4 t
<br /> CTOR LIC.#REQUIRED: - CITY OF EVERETT BUSINy LIC.#(REQUIRED): ® rCONTRA ( ) v .. �. . , .�, r_..,..
<br /> PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: • CONTACT PHONE: C.LO ,, 2,b 1 tZ1 •
<br /> r c41 Yk CONTACT EMAIL: /M IV6�.�VI ( ,Is^ ig� I •
<br /> AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title City of Everitt Official Use Only
<br /> 14 Water and Sewer or such other rules and regulations now existing or which maybe established from time to
<br /> time. The applicant further agrees, a con i"n precedent to receiving service that the utilities division shall have FEE . r`ti
<br /> the right at any " e,w" t notic ,to shut off o turn on the water supply for repairs,construction,and
<br /> nonpayment fch r s or or an otherreasona le cause.lam the owner,or am authorized by the owner of this b
<br /> property top or he wo hich applicano is made,and I comply with the State Contractors Law 18.27 PERMIT#
<br /> RCW and 29 200 WAC
<br /> 0o1ov1
<br /> i)Ci gent Sig ature Date (Revised 10/12/2015)
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