Laserfiche WebLink
NINE WATER / SEWER UTILITY APPLICATION <br />CITY OF EVERETT PERMIT SERVICES <br />EVERETT SUBMITTAL INSTRUCTIONS: Grop off led copy paper appliwaon& plane 10 320D Ceder street Carl FEW Intake Drop am <br />CONTACT INFORMATION: (P) 425-257-B910I (E) Permit£ervices®everMlwa.gov I (W) eveMlwa.goNparmi(a <br />PROJECT SITE IN <br />PROJECT ADDRESS: <br />1IFORMATIO <br />pN <br />6 ftT`T WA. t37-03 <br />IFAPPLICABLE: ❑OUTSIDE CITY LI <br />Ts ❑ BUROINGAREA SF El LOT If <br />BUILDING TYPE: OSFR OTOWNHOUSE QDUi OADU OMULTI-FAMILY-YOF UNITS:_ <br />COMMERCIAL OACCESSORY <br />CHANGE OF USE? NO ❑YES• FROM TO <br />UTILITY APPLICATION INFORMATION <br />SEWER check all that apply) <br />WATER (check all that apply) <br />SIDE SEWER REPAIR <br />❑ SIDE SEWER ALTERATION <br />❑ NEW SIDE SEWER INSTALLATION <br />❑ INSTALL BACKWATER VALVE VatrUade the building) <br />❑ SIDE SEWER CAP -OFF <br />❑ SIDE SEWER RECONNECTION <br />O BACKFLOW PREVENTION (Outside) - Speclly device type below: <br />ORPBA(domJ LDCVA(dl ODCVAprr.) ODCDA(fre) <br />O WATER LINE BEHIND METER(repar or alteration) <br />O NEW WATER SERVICE INSTALLATION <br />Spaclfylnsrallatlon typo below: <br />❑ NEW COMPLETE SERVICE <br />❑METER ONLY <br />Spedfy wousr sarv/ce type B size below: <br />❑DOMESTIC: 7131P' LP' 02" OCdvo <br />0IRRIGATION: OWN' 01" LJZ OCMer: <br />❑FIRE: OP' Or Oa" 06" Oa" OOMer. <br />❑ DOMESTICIFIRE COMBO: ❑i" LT' OOMen <br />MULTIPLE DOMESTIC WATER SERVICES REQUEST <br />❑ I 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 MULTIFAMILYDEVELOPMENT UNDER <br />SINGLE OWNERSHIP. FILL OUTREVERSE SIDE OF MIS FORM. <br />CONTACT INFORMATION <br />OWNER NAME: / TENANT BUSINESS NAME If Cammertla:LrOlds <br />OWNER MAILING ADDRESS: S . 634 Aj trr ✓e. {a- �4 <br />as <br />Lv<FL+F SIAMt.✓q zip g72d3 <br />OWNER PHONE: <br />OWNER EMAIL : <br />��11 <br />{PI <br />CONTRACTORNAME: .✓My1k1 S+.Wv ve( nai <br />CONTRACTORADDRESS: STREU g7,1`1 7;LI S'F SW <br />a. w. aTa ur zv,l z,6' <br />745 <br />CONTRACTORPHONE: Zoi (m IB12 <br />CONTRACTOR EMAIL: <br />d4r'Ir<{ LWL/anQ Min. fUYh <br />CONTRACTORLIC.SREOUIREC): <br />S Sizz CITY OFEVERETFBUSINEBEUC. REQUIRED):6So( <br />PRIMARYCONTACT: DOWNER ❑CONTRACTOR ❑ OTHER (Please Specify) <br />CONTACTNAME: <br />AvAObtastMLDgy,;,,� <br />CONTACTPHONE: Licii— <br />I Ez <br />1 <br />CONTACTEMAIL: (�IAThUY1 <br />fana�3 w•t�gv. dvw .fUt <br />AGREEMENT: iM im�'cpnedepptma sgreeabcmlpj'e1111eppawbrudllre Everett Murvsipal Coh Tifb)d Wale'aiNSe�reswatClldM/vkaeMrepubxms cox <br />.xblinpwwnm.rNaa*raarxnaamm nmem lme. rnewtaarttmnlreraglmx aaadrexlMn preaaaamroreamripaarvneur.lrrcaasiMaxwMronamxln.alrc.rcnlal <br />amr, .rMhMMke. baM1WMa'Mamllsrveierauppryln repairs[orulm[Lin eNMArgymeNddumes vMamalarnammeMMme. lam nrewvnar. wlem <br />euThwrteaey lremme.dtrila yopenr to Paamntrc nwkbrrMeeb eagiaallmumaM,am Iconwylwin per SEE Gmr"ImPLan ten RCuvanansN wac <br />Cr, o/EverNf OlMlel Use Oa <br />PERMITO <br />����•� s-i-z� U 2305- Do I <br />ownenAWnodzea III signature Care TrrfaMW1e2022) <br />