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2016-07-2� 14:51 PSPH364DN 12069376622 » 425 257 8857 <br />P 1/1 <br />WATER / SEINER UTILITY APPLICATIOlV <br />CITY OF EVERETT PERMI7 SEF2VICES <br />3200 CEDAR STREET, EVERE7T, WA 9g201 <br />(P) 425-257-8810 ( FAX 425�257-5857 ((E} everetteps�d�verettwa.gov � v�nvw.everettwa.gov�permits <br />, _. <br />P�eC��ec-r' SIT� IN�OI�l1l�/�"�to�+t. ' , <br />PROJECT ADDRES3= IG oC(� D �/' �'1 � t�e. �YP.� �U,� %$'o?�� <br />IF APPLICABL�: ❑ OUTSIDE CITY LIMITS ❑ BUIL�ING AREA SF ❑ LOT #! <br />BUILDING TYP�: �SFR-DETAC:HED OSFR-ATTACWEU ❑OULEX OMULTI-FAMILY�t OF UNITS: ❑COMMFRGIYiL ❑INUUS I i�lAl_ <br />CHANGE OF US�? � N� i� Y�S, FROM TO <br />; . <br />�:: <br />,ur�l�1"�"Y ar�P��cAT1aN.�N�oaM�T#a1� I <br />SEW�R (check alt that apply) V10ATER (check all fhat apply} <br />� S10� SEWER REPAIR � NEW 1Nl�TEFt SERVICE INSTALLATIO�! <br />❑ SIDE SEWER ALTERATIGN ❑ COMPLETE SERViCE C] METER ONLY <br />0 NEW 51DE SEWER tNSTAlLATION SERViCE / MEiER USE: <br />0 INSTALL 6ACKWATER VALVE (o i the b�iilding) C7 5FR <br />C� SIbE SEWER CAP-OFF ❑ MULY!•FAMILY -# OF UNITS; <br />❑ 51DE SEWER RECONNECTION ❑ COMMERCIAL <br />MULTIPLE DOME3TIC WATER SERVICES REQUEST Wqi�R SERVlCE TYPE / SIZ6: (circle desired size) <br />� I AM DECLINI��G MULTIPLE DOMESTIC WATER SERVICES FOR Q C10MFSTiC: 3/4", 1", 2", OTMER' <br />MY MULiI-FAMIL.Y DEV�LdPMENT UND�R SINGLE OWNERSHIP. ❑ IRRIGATION; 3/4", 1", 2", OTHER_ <br />Q I AM OPTING TO INSTALL MULTiPLE DOMESTfC WATER ❑ FIREr 1", 2", 4", 6", 8", OTHER: <br />SERVICES FOR MY fv9ULTl-FAMILY DEVELOPM�NT UNDER ❑ D�MESTiC/FIRE COM�O; t", 2", pTH�R: <br />SINGI_E OWNERSHIP. FlLL OUT REVERSE SlDE OF TMIS FORM. <br />,.. ... <br />COi�ITACT:.IN,P <br />NER NAME; a TENAMT NAME (If Com <br />NER MAILING ADDRESS: srn�er Q <br />i.ir� �- <br />NER PHONE: ��✓ _�(1� ^ D/� �WNER EMAIL: <br />�TRACTOR NAME� NI1%%A_T . n11M �//17i�I1 Yl /1 <br />CONTRACTpR ADDRESS: ✓ srRFFr /1 SD.� Des ,b�pf�J�s /� <br />c�n urJG!`% <br />CONTRACTOR PHONE: O7U�O— ��O ^� o�Z 1 CONTRAC70R EMAiL: f,( <br />CONTRACTOF2 `IG. # REQUIRED): Pl� G� /�� p2 �� GTY OF' E ERE <br />PRIMARY CONTACT: ❑ OWNER �CONTRACTOR � OTHER (Please Specify) _ <br />CONTAC7 NAME: CONTACT PHONE: aD(Q <br />� � �ar�d e I CC}NTACi EMAEL• (� �o� <br />AGREEMENT: rhe un�le/srQned avD�lcant egrees fn romp)y with all provis�ona o} the evem,(1 M��nicipa! ,ode Trf(e <br />�a �yaler and Sewer or aucn otner �t�le�� xnd regulafions now ex(g1%ny ur which may be esreblianed m7m lfrne fo <br />nme. TMe a�?pticant further egrees, eg e Condifion precedent ro recelv;ng gn�co !hat lhe urilrAea arvrsron sn,9U I�Pvo <br />fhe npht et eny tvne, wJfhout notrce. to shut of! or tuat un /i�� wator supply for �vpeirs, rp�o; hi�Cfivn. and <br />�anpayment of chai�es or lor any ofher reasonable cause. / am the owner, ol' 1 am autltonzed 6y fhe nwner Of th15 <br />plt7Ae�ty t0 pedorm the work tor whlCh Witah'on is made, end I �pmply with fhe State Confrectors Law 16.77 <br />RCW -n 286.200A WAG, <br />-� r�,��1 o7la�lao�� <br />Ag6nt 5ignaty� pe�e <br />F,rr�a�lPol � 7,J�a�i � � S� 394m � <br />RT/+TE <br />-c-r / , <br />°/11L <br />�TnTE <br />��i <br />PT �U: <br />� /l. <br />�S LIC. #{R�QIJIR�fl); ��5%}, I j <br />- �'�� / � <br />�_G �_I __i-__ ^ . <br />Cityl�f Evgref7 U(fi�! Use`�nly <br />FEE %��>� <br />� -/ <br />PERMIT # <br />UII����'�-�)� <br />(Rewsed i0/12/2076) <br />