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ONES WATER I SEWER UTILITY APPLICATION <br />CITY OF EVERETT PERMIT SERVICES <br />EVERETT SUBMITTAL INSTRUCTIONS: Drop off haN copy paper appllcalbn8 plans 03200 Cedar Street Said Flow Intake Drop Box. <br />WAMINGTOn CONTACT INFORMATION: (P)425.257.88101(E)l(W) evarettwe.0ovlpmmila <br />PROJECT SITE INFORMATION <br />ROAECT AOORESS: 6 tS S}- u Evt/tiT+ W <br />R <br />WAPPLICABLE: ❑ OUTSIDE CITY LIMITS ❑BUILDING AREA SF ❑LOTH <br />BUILDINGTYPE: b6SFR OTOWNHOUSE ODUIo-X OADU OMULTPFAMILYNOFUNRS: OCOMMERCNL OAGGESSORY <br />CHANGE OF USE? ONO DYES, FROM TO <br />UTILITY APPLICATION INFORMATION <br />SEWER (check all that apply) <br />WATER (check all that apply) <br />❑ SIOE SEWER REPAIR <br />❑ SIDE SEWER ALTERATION <br />❑ NEW SIDE SEWER INSTALLATION <br />❑INSTALLBACKWATERVALVE( amd thebuilding) <br />❑ SIDE SEWER CAP -OFF <br />❑ SIDE SEWER RECONNECTION <br />❑ BACNFLOW PREVENTION (OutsMe)- Specify dWce type below: <br />ORPBA(dom.) ODCVA(dorn.) ODGVA(Irr.) ODCDA(bm) <br />O WATER LINE BEHIND METED hapair Or alteration) <br />NEW WATER SERVICE INSTALLATION <br />SMOectry Installation type below: <br />ANEW COMPLETE FICCE1 '-^',-l-L_1.,� <br />ClMETER ONLY /..Y eI// -V'I1,Lt-11(-ya-'N s'I W'fOL'i�1AN/r/ <br />Specify weIsrservke typ,,eJe""S� a xeb& <br />(DOMESTIC: ApI(W4- Oi' DY' 000er: <br />IRRIGATION: 0314' 11v Or OOlher: <br />❑FIRE: 01" 02- 04" 06" 08- 00ther: <br />❑ DOMESTICIFIRE COMBO: Ot' OY' 000er: <br />MULTIPLE DOMESTIC WATER SERVICES REQUEST <br />❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR <br />MY MULTI -FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. <br />❑IAM OPTING TO INSTALL MULTIPLE DOMESTICWATER <br />SERVICES FOR MY MULTI -FAMILY DEVELOPMENT UNDER <br />SINGLE OWNERSHIP. FILL OUTREVERSESIDE OF THIS FORM. <br />CONTACT INFORMATION <br />rr <br />v�cl� <br />WNERNAME: 3tQ l(i1 is`ai t'r TENANT BUSINESS NAME IN Commerclel: <br />OWNER MAILING ADDRESS: ET st% 16 LaILfSYUAV'C DP acinr <br />Lov-e S1eNeM SP <br />OWNERPHONE: 41-LS-530-9u�l <br />- �.AP <br />1OWNEREMAIL. <br />CONTRACTOR NAME: <br />CONTRACTOR ADDRESS:SFEET <br />cry <br />CONTRACTOR PHONE: <br />CONTRACTOR EMAIL: <br />CONTMCTOR LIC. YRREOOIREO): CITY OF EVERETT BUSINESS LIC. #(REQUIRED): <br />PRIMARY CONTACT: ❑OWNER ❑GONTRACTOR ❑OTHER (Please SpeclTy) _ <br />CONTACTNAME: <br />CONTACT PHONE: <br />CONTACT EMAIL: <br />CP WEverell ORltlelUm On <br />PERMITK <br />�J 2'zo(Q-o32 <br />(Remaad WAT021) <br />LI/ <br />