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WATER / STF,VViER UTE 1 T Y APPL CATON CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P) 425-257-8810 I FAX 425-257-8857 I (E) everetteps@everettwa.gov I www.everettwa.gov/permits —PROJECT SETT E INFO '1311 4TI-)\l PROJECT ADDRESS: (0 VVV1-p« fm-e- . IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX DMULTI-FAMILY-#OF UNITS: DCOMMERCIAL DINDUSTRIAL CHANGE OF USE? ,NO ❑YES, FROM TO UTILITY APPUOCATI INFORMATI I I,I SEWER(check all that apply) WATER(check all that apply) SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION ❑ SIDE SEWER ALTERATION 0 COMPLETE SERVICE ❑ METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: O INSTALL BACKWATER VALVE (outside the building) 0 SFR ❑ SIDE SEWER CAP-OFF 0 MULTI-FAMILY-#OF UNITS: ❑ SIDE SEWER RECONNECTION 0 COMMERCIAL MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE: (circle desired size) O I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR ❑ DOMESTIC: 3/4", 1", 2", OTHER: MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ IRRIGATION: 3/4", 1", 2", OTHER: ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑ FIRE: 1", 2", 4", 6", 8", OTHER: SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER ❑ DOMESTIC/FIRE COMBO: 1", 2", OTHER: SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. i CONTACT INFORMATION OWNER NAME: 't Ht I L( De"I 1 'V/ TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET `bI(.0 on, c iii--i CITY STATE VV V I • ZIP lq Z6 f OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: V J w' 19 tim rk ii,, i, CONTRACTOR ADDRESS: STREETeAtara 1 \,I16 Py/ " °,d CITY STATE WA . ZIP 410 CONTRACTOR PHONE:LitA DC2 CO TRACTOR EMAIL:etA,�� A P°,° 1 � 1 O CONTRACTOR LIC.#(REQUIRED): IA .r-f CITY OF EVERETT BUSIN LIC.#(REQUIRED 0 PRIMARY CONTACT: ❑OWNER ❑ CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: '9(421 , '0,6, I, % , V (v_1 CONTACT EMAIL: 7 ic 291410 ''I team 9 AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Ctode Title City of Evert Official Use Only 14 Water and Sewer or such other rules and regulations now existing or which maybe established from time to FEE time. The applicant further agrees, a con t' n precedent to receiving service that the utilities division shall have a the right at any ' e,w" . t notic',to shut off o turn on the water supply for repairs,construction,and �f nonpayment.f ch,r.-s or or an other reasona le cause.I am the owner,or l am authorized by the owner of this 'fl. __ l property top- or he wo • hich applicatno is made,and I comply with the State Contractors Law 18.27 PERMIT RCW and 29:200 WAC . �, U I / V l �ti J V Ir f (`tn wner/Authoriz-:�,,gent Siglature Date (Revised 10/12/2015)