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WATER / SEWER UTILITY APPLICATION <br />CITY OF EVERETT PERMIT SERVICES <br />3200 CEDAR STREET, EVEREFT, WA 98201 <br />(P) 425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everethva gov/peirnds <br />PROJI"CT SITE INFORMATION <br />PROJECT ADDRESS: <br />IF APPLICABLE: <br />❑ OUTSIDE CITY LIM S ❑ BUILDING AREA SF ❑ LOT # <br />BUILDING TYPE: <br />❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX 0MULTI-FAMILY4 OF UNITS:_ ❑COMMERCIAL ❑INDUSTRIAL <br />CHANGE OF USE? <br />❑ NO ❑ YES, FROM Tn <br />I• UTILITY APPLICATION INFORMATION <br />SEWER (check all that apply) WATER (check all that aoDly) <br />❑ SIDE SEWER REPAIR <br />❑ SIDE SEWER ALTERATION <br />❑ NEW SIDE SEWER INSTALLATION <br />INSTALL BACKWATER VALVE outside the building) <br />❑ SIDE SEWER CAP -OFF <br />❑ SIDE SEWER RECONNECTION <br />I MULTIPLE DOMESTIC WATER SERVICES REQUEST <br />❑ 1 AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR <br />MY MULTI -FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP <br />❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER <br />SERVICES FOR MY MULTI -FAMILY DEVELOPMENT UNDER <br />SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. <br />❑ NEW WATER SERVICE INSTALLATION <br />❑ COMPLETE SERVICE ❑ METER ONLY <br />SERVICE I METER USE: ` <br />❑ SFR <br />❑ MULTI -FAMILY -# OF UNITS: <br />❑ COMMERCIAL <br />WATER SERVICE TYPE I SIZE: (circle desired size) <br />❑ DOMESTIC: W4", 1", 2", OTHER: _ <br />❑ IRRIGATION: 314", 1", 2", OTHER: _ <br />❑ FIRE: V% 2", 4", 6% 8", OTHER: _ <br />❑ DOMES11CIFIRE COMBO: 1", 2", OTHER: <br />CONTACT INFORMATION <br />OWNER NAME: <br />WhA r ri TENANT NAME (If Commercial): <br />OWNER MAILING ADDRESS: SMEer 90 box <br />I <br />cm 1 <br />t/1 STAR[ <br />L.' <br />OWNER PHONE: <br />OWNER EMAIL: <br />CONTRACTOR NAME: R\ <br />CONTRACTOR ADDRESS: STREET <br />CITY <br />STATEym <br />ZP <br />CONTRACTOR PHONE: <br />�' <br />CONTRACTOR EMAIL: <br />CONTRACTOR LIC. #(REQUIRED):EVER'ITT <br />BUSINESS LIC. #(REQUIRED): <br />PRIMARY CONTACT: ❑ OWNER IgCONTRACTOR ❑ OTHER (Please Specify) <br />CONTACT NAME: <br />VD' 41' l <br />CONTACT PHONE: �, �� <br />CONTACT EMAIL: <br />AGREEMENT The undersigned applicant agrees to comply with all provisions of the Evemft Municipal Code Title <br />14 Water and Sewer or such otherrulas and regulations now existing or which maybe established from time to <br />time. The applicant further agrees, as a condition precedent to receiving service that the utilities division shall have <br />the tight at anytime, without notice shut off turn on the watersupply for repairs, construction, and <br />nonpaymen chargesorfor yothe asonable cause. I am the owner, or l am authorized by the ownerof this <br />Pm o pert, ork or which a Ikalion Is made, and I comply with the State Contractors Law 16.27 <br />and 296. OA A . <br />City of Everett On tat Use Only <br />FEE <br />^ D " <br />PERM11 h <br />UI5►2-031 _j <br />(Revised 101122015) <br />