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(P) 425-257-8810 <br />WATER / �EWER UTILITY APPLICATION <br />CITY OF EVERETT PERMIT SERVICES <br />3200 CEDAR STREET, EVERETT, WA 98201 <br />FAX 425-257-8857 �(E) everetteps@everettwa.gov � www.everettwa.gov/permits <br />PROJECT SITE INFORMATION <br />PROJECT ADDRESS: �i�% �- � N�f�C:Q. I,..���t'� ��j���`�" <br />IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT # <br />BUILDING TYPE: SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-# OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL <br />CHANGE OF USE? N� ❑ YES, FROM TO <br />UTILITY APPLICATION INFORMATION <br />SEWER (check ail that apply) WATER (check all that apply) <br />�SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION <br />I+G�SIDE SEWER ALTERATION ��'st�f�C„� �[;�Ct2'�� '�./ ❑ COMPLETE SERVICE ❑ METER ONLY <br />❑ NEW SIDE SEWER INSTALLATION �I�S �%�P� SERVICE / METER USE: <br />❑ INSTALL BACKWATER VALVE outside the building) ❑ SFR <br />❑ SIDE SEWER CAP-OFF ❑ MULTI-FAMILY -# OF UNITS: <br />❑ SIDE SEWER RECONNECTION ❑ COMMERCIAL <br />MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE / SIZE: (circle desired size) <br />❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR ❑ DOMESTIC: 3/4", 1", 2", OTHER: <br />MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ IRRIGATION: 3/4", 1", 2", OTHER: <br />❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑ FIRE: 1", 2", 4", 6", 8", OTHER: <br />SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER ❑ DOMESTIClFIRE COMBO: 1", 2", OTHER: <br />SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. <br />CONTACT INFORMATION <br />OWNER NAME: "��� <br />8 �fti'i. � Fr.1 s.� TENANT NAME (If Commercial): <br />OWNER MAILING ADDRESS: sTrzEET ��,,Z � ��.y��2 ���!� <br />CI7Y � ���-L 1 STATE � � ZIP =/��`� � <br />OWNER PHONE: �U�c+ `.j�G4"���� � OWNER EMAIL: ��+.,��a�ra�`� �' �'►`�Z���. ��'� <br />CONTRACTOR NAME: <br />CONTRACTOR ADDRESS: srReer <br />CITY STATE ZIP <br />CONTRACTOR PHONE: CONTRACTOR EMAIL: <br />CONTRACTOR LIC. #(REQUIRED): CITY OF EVERETT BUSINESS LIC. #(RECIUIRED): <br />PRIMARY CONTACT: OWNER ❑ CONTRAGTOR ❑ OTHER (Please Specify) <br />CONTACT NAME: CONTACT PHONE: <br />CONTACT EMAIL: <br />AGREEMENT.� The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title <br />14 Water and Sewer or such other ru/es and regulations now existing or which may be established f�om time to <br />time. The applicant further agrees, as a condition precedent to receiving service that the utilities division sha/l have <br />the right at any time, without notice, to shuf off or turn on the water supply for repairs, construction, and <br />nonpayment of charges or for any other reasonable cause. l am the owner, or I am authorized by the owner of this <br />property to perform the work for which_ pplication is made, and I comply with the State Contractors Law 18.27 <br />RCW and 296.200A WAC ,,,�-- <br />�.e _ �, ,,�� -�=�--�—` <br />Owner/Authorized Agent Signature <br />Date <br />City of Everetf Official Use Only <br />FEE „ ` � <br />i\ �j Jl <br />PERMIT # <br />U 1 I,r��S- �0� <br />(Revised 10/12/2015) <br />�;; ; <br />� <br />