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�� WATER I SEWERUTILITY P. L ��CAT U l • 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 "� If/ PROJECT SITE IINFI RMATION '� PROJECT ADDRESS: 17, I l� I/I I (A.' lj .— —IF APPLICABLE: ❑ OUTSIDE CITY LIMI1S ❑ BUILDING AREA SF ❑ LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? NO ❑YES, FROM TO UTILITY APPLICATION INFORMATION SEWER(check all that apply) WATER(check all that apply) f 0.SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION ❑ SIDE SEWER ALTERATION ❑ COMPLETE SERVICE ❑ METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: INSTALL BACKWATER VALVE(outside the building ❑ SFR ❑ SIDE SEWER CAP-OFF ❑ MULTI-FAMILY-#OF UNITS: ❑ SIDE SEWER RECONNECTION ❑ COMMERCIAL MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE: (circle desired size) ❑ 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. CONTACT INFO—(CATION OWNER NAME: V 7 1011 I(A - TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET 0I 1i a 1 \ `GIB CITY STATE it ' F. ZIP Ci S -6 OWNER PHONE: ��,f��/�� OWNER EMAIL: CONTRACTOR NAME: 4 pc CONTRACTOR ADDRESS: STREET 1 Ni h"AVA ► 1 1' vt .A i , CITY STATE wa • ZIP '$ ,66 CONTRACTOR PHONE: i ) '`, ®l2 CO TRACTOR EMAIL: LtAkt 1 ' ,I, l l Oi ` I Al .YJV It u I � CITY OF EVERETT BUSIN LIC. •#REQUIRED f r CONTRACTOR LIC.#(REQUIRED): ,6 �, IA V _ t I PD ( )' 051 6.. PRIMARY CONTACT: ❑OWNER ❑ CONTRACTOR ❑ OTHER(Please Specify) CONTACT av NAME: CONTACT PHONE: L �9 Zb II of 1 �@ (� `��ft d r/ �✓ CONTACT EMAIL: A(MqI)I imYlIemini tic 16�1I�f �t9',& a6 C/�/ AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal(lode Title City of Everitt Official Use Only 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to FEE time. The applicant further agrees, a con i'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 i{:7 (� nonpayment.fch"r•-s or or an other reasona le cause. I am the owner, or l am authorized by the owner of this property to p• or he wo hich applicatio is made,and I comply with the State Contractors Law 18.27 PERMIT ist RCW and 29;200• WAC fit , u H90 - 02q) __ OwnerlAuthoriz .� gent Siglature Date (Revised 10/12/2015)