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V1le� �R / SEWER IJiILIiY �LI�ATION <br />CITY OF EVERETT PERMIT SERVICES <br />3200 CEDAR STREET, EVERETT, WA 98201 <br />(P) 425-257-8810 � FAX 425-257-8857 �(E) everetteps@everettwa.gov � www.everettwa.gov/permits <br />PROJECT SITE INFORMATION <br />PROJECT ADDRESS: � � I � G( `j� �' • > � C.C,' c C' � �� <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? ❑ NO ❑ YES, FROM TO <br />UTILITY APPLICATION INFORMATION <br />SEWER (check all that apply) WATER (check all that apply) <br />❑ SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION <br />❑ SIDE SEWER ALTERATION ❑ COMPLETE SERVICE ❑ METER ONLY <br />�NEW SIDE SEWER INSTALLATION 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 ❑ DOMESTIC/FIRE COMBO: 1", 2", OTHER: <br />SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF TH1S FORM. <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 rules and regulations now existing or wliich may be esfablished f�om time to <br />fime. The applicant further agrees, as a condition precedent to receiving service ihat the utilities division shall have <br />fhe right at any time, without notice, to shuf off or tu�n on the wafer supply for repairs, consfruction, and <br />nonpayment of charges or for any other reasonable cause. 1 am the owner, or 1 am authorized by the owner of this <br />property to peiform the wo�k for which application is made, and 1 comply with iire State Confractors Law 18.27 <br />RCW and 296.200A WAC, <br />�/��-��'c� �e��rc- �'�' ./���'����� 7-2 5� - � <br />Owner/Authorized Agent Signature Date <br />City of Everett Officral Use Only <br />FEE <br />.� �,� /'l� i � �� � � ��� <br />�-' �/ , / <br />PERMIT # <br />U ' ��i��' —����";� <br />(Revised 10/12/2015) <br />