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+ WATER / SEWER UTILITY APPLICATIC)N <br />CITY OF EVERETT pERM{T SERVICES <br />3200 CEDAR Si'REEF, EVERETT, WA $82t�3 <br />(F} 425-257-88'!0 [ FA)C 425-257-8857 �(E) everettepst�ewerekfw�a.gov � www.evecettvwa.gavlpermits <br />PRt1,�ECT $ITE #NFCiRMATiQN <br />A3lDRE5S: `-'� 1� l i t� <br />APPUCASLE: ❑ OUTSIdE CtTY LIMITS ❑ BUILDlNG AREA S <br />1ELDING TYPE: �SFR-0ETACNED �SFR-ATTACHEI7 CIDULEX ❑MUlT4 FAMiLY-# OF UIVlT� <br />iANGE OF USE? �NO � YES, FRdfU! T� <br />UTtL1TY APPLICATION tNFO�tNlATIC?N <br />SEWER (check al! that apply} WATER G <br />I� SIQE 5EW€f2 REPAtR <br />❑ SIDE SEWER ALTERATION <br />❑ NEW SIDE SEWEi2 IAtSTALLATiC3N <br />❑ INSTALL BACKV1tRTER VALVE (outside the building) <br />❑ SIDE SEWER CAP-OFF <br />❑ SIDE SE�AiER RECOh3NEC7(Oht <br />MULTIPl.E #�C�ESTIC WATER �ER'YICES � <br />� i AM DECLiNtNG �iJLTIPLE Dt7M�S7"IC WATER SERVICES FOR <br />MY MULTI-FAM(LY DEVELC}pMENT Uf+tDER SINGLE OWi�1EftStilP <br />❑ 1 AM OPTING T4 {NSTAL� Ml1LTIP�E DOMESTIC WATER <br />SERVlCES Ft7R NfY MULTt-FAMILY DEVELOPMENT UF{DEf2 <br />SINGLE f}WAIERSiiiP. F/LL OUT REYERSE SiDE OF TH/S Ff}RM. <br />❑ LOT # <br />i�COIVIMERCIAL �INDUSTFtiR� <br />a!I that <br />❑ i�EW WATER SERViGE 1N8Tift�LAT}Oh1 <br />❑ COtVIPLETE SERVIGE � METER ONLY <br />S�fZVICE t METER USE: <br />Q SFR <br />❑ MULTI-FANtitY - # QF UNtTS: <br />❑ CO[ufNtERClAL <br />VYATEF� SERIt[CE TYPE 1 S[ZE; feircie desired size) <br />� C3C}I1�ESTIC: 3i4". 1", 2" CITHER� <br />� iRRiCsATIflN: <br />❑ FIRE: �„ 2,. <br />❑ QQMESTIC/FlRE COMBC�: <br />314", 1". 2", OTHER� <br />4'�� 6". 8", C}TFlER: <br />1", 2", OTHER: <br />--- ...,.N.Y „.,,,, a„ +»�,.�,a,r,s or rrre tve+aa naunicrpat eoa'e 7iUe <br />14 iMater and Sewer ar such other rules and reyuiations now existing or which may txe estabtished fmrYr tirne tc� <br />time. The a,opt(cant turthe� agr�es, as a conddion prece�/e�t to reoeiving servi�s tlrat the utilities division shall have <br />tire riAht at any time, witt�or�t notice, fu shut otf or tvm on the water suppfy !qr repairs, construction, and <br />nonpayment of charges or /nr any other reasonabl� cause. 1 am the awrtEr, or 1 am authorized by Uie owrrer of fhis <br />p to pe�form The work for wh' ppticatron is mada, 1 compJy with the State Coniractors Law �827 <br />R�CW a 96.200A W . <br />� � � - l� <br />oW��, � o��� i w �ace <br />City of Evere#t O�ciat tlse Only <br />FEE"'���'""`_�"'._ <br />� � �— <br />PERMIT # <br />� 1 C� � � - ��f �I <br />(Revised tQ/i2l20f5) <br />