10131 MONTANA RD 2016-08-25 - Laserfiche WebLink

WATER / SEiNER UTILITY APPLICATI4N CITY OF EVERETT PERMIT SERVICES 3200 CE�AR STREET, EVERETT, WA 98201 FAX 425-257-8857 �(E� everetteps@everettwa.gov � www.everettwa.gov/permits � � UTILITY APPLICATION� 1N�ORMATIf�N � � � �� SEWER (check all that apply) WATER (check all that appiy) SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTAI.LATIQN ❑ SIDE SEWER A�TERATION ❑ CC3MPLETE SERVICE ❑ METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE / METER USE ❑ INSTALL BACKWATER VALVE (outside the building) ❑ SFR ❑ SlDE SEWER GAP-OFF ❑ MULTI-FAMILY-# OF UNITS: 0$tQE SEWER RECONNECTIt7N � C�MMERCIAL MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYRE ! SIZE: (circle desired size� ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES �OR ❑ OOMESTIC: 314", 1", 2", OTHER: MY MULTI-FAMILY DEVELOPMENT UNDER 51NG�E OWNER5HIP. ❑ IRRIGATION: 3(4". 1", 2", OTHER: ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑ FIRE: 1". 2", 4", 6", 8", OTHER: SERVICES FdR MY MULTI-FAMILY DEVELOPMENT UNDER ❑ DOMESTIC/FIRE COMBO: 1", 2", OTHER: SINGLE OWNERSHIP. FlLL OUT REVERSE S1UE OF THIS FDRM. 14 Weter and Sewer or such other rules nnd regulations now exrsting a which may 6e established fr�m time to time. The applicant furtner agrees. as a condition precedeni to recerving service [hat the utilities division shal! have the rrghi ac any Ume, wrthour norice, to shut off or turn on the water suppry for repairs. construction. and non�ayment of charges or for any other reasonable, cause. f am the owner, or ! am authorized by the owner of this property to perfa�rtt the work for w ch appGcatron is made, and ! comply with the Sta[e Contractors Law 18.27 R a d 296.200A WAC. ��C�� Own r/Authorized A nt g ature Date FEE ��^ r�� V� PERMIT # �� U - (Revrsed f0/72/20?5)