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WATER / SEWER UTILITY APPLICATION <br />CITY OF EVERETT PERMIT SERVICES <br />EVERETT <br />SUBMITTAL INSTRUCTIONS: Drop a had copy paper epplKatlon&Plans on 3200 CWar Street2nd Floor Intake Drop Box <br />WASHINWTON <br />CONTACT INFORMATION: (P) 025257-BB10 ) (E) PelmkServicea0everespagov I (W) evereXwa.govenemii6 <br />PROJECT SITE INFORMATION <br />PROJECT ADDRESS: <br />IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILOINGAREA SF ❑LOT# <br />BUILDING TYPE: BSFR OTOWNHOUSE ODUPUE OADU 0MULTI-FAMILY40FUNITS:_ OCOMMERCN OACCESSORY <br />CHANGE OF USE? D13'NO ❑ YES, FROM TO <br />UTILITY APPLICATION INFORMATION <br />SEWER (check all that apply) <br />WATER (check all Mal apply) <br />SIDE SEWER REPAIR <br />❑SIDESEWERALTERATION <br />❑ NEW SIDE SEWER INSTALLATION <br />❑ INSTALL BACKWATER VALVE(outsitle Me buildiWo <br />❑ SIDE SEWER CAP -OFF <br />❑ SIDE SEWER RECONNECTON <br />❑ BACKFLOW PREVENTION (Outside) - Specify Device type below: <br />ORPBA(daln.) ODCVA(dwn.) OOCVA(Ilr.) ODCDA(fire) <br />❑ WATER LINE BEHIND METER hapair or alteration) <br />O NEW WATER SERVICE INSTALLATION <br />Specfy lnaMlbflon type Uefow: <br />❑ NEW COMPLETE SERVICE <br />OMETER ONLY <br />Specify waMrurvwa type&are below: <br />❑DOMESTIC: 034' 01' 02' OOINen <br />❑IRRIGATION. OWN. ❑1' 02" ODfilerl <br />❑FIRE: O1"O2" OF' 06" Ofi"OONer: <br />❑ OOMESTIQFIRE COMBO. 01" 11T OOlher <br />MULTIPLE DOMESTIC WATER SERVICES REQUEST <br />O 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 MULTI- FAMILY OEVELOPMEM UNDER <br />SINGLE OWNERSHIP. FILL OUI REVENSE SIDE OFTNIS FORM <br />CONTACT INFORMATION <br />OWNER NAME: TENANT BUSINESS NAME (N Commercial). <br />OWNER MAILING ADDRESS: <br />- STATE O <br />OWNER PHONE: <br />IOWNEREMAIL I/7ESGE' .FS H G•Lt��7 <br />ONTRACTORNAME: <br />ONTRACTORADDREBB: smsr=Jr VD <br />m { <br />CONTRACTOR PHONE: -O <br />CONTRACTOR EMAIL: <br />CONTRACTOR LIC.#REQUIRE )9 CITY OF EVERETT BUSINESS LIC.#FEQUIRED: <br />PRIMARY CONTACT: ❑OWNER IrMNTRACTOR ❑ OTHER (Please Speorho <br />CONTACT NAME: % �NIJl3 <br />CONTACT PHONE: c20_-Or'?00 <br />CONTACT EMAIL: <br />AGREEMENT. no unaPapnMBFpVb:uegawrosmpr.;m.aponsmswmB Erm#.Nuniipel Ce]e TmB 1a N'Brer.msewe.wsucnmrerupBBna,B¢Bkmns no. <br />exlskgwxfii[h mry Ltl eafMPNBOFom limBbM1nN. iM Bq%wnt rwflinepree{ eee mm.5fim gxeRnt fo mcvAp eerv/reth�� Me uMl'es G'viBicn.wanne.emB.ynf at <br />anyone, M nxaMe,roNlufMwhvn on Me wrersuppyrorreptirt,aneMlchen.BMnmpaymanrorvJrsge:erkr Bnromerreexinepgwum. l am mB umer, cot wo <br />Benno,ureymeownermttiopmPatympB,mim me week mr»ea BppxeBa,,.;: mBx find l eonMymtn r, smre C,,MwM stow ran RCWBne2ss zow wac. <br />aEvgatl WFClal llm pl <br />//t/2M'1 ldV—riT'�-ricJ lJ ��O W <br />OwnMAUNPMOApntl Slprslun Oele (Reviw/N111M22) <br />