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, <br />(P) 425-257-8810 <br />WATER / SEWER 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: �'�j C S ��r� SS� �� � 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? ❑ 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 THIS FORM. <br />CONTACT INFORMATION <br />OWNER NAME: j'� l� L� �` -� �= >; 1 C �?�� � L �� TENANT NAME (If Commercial): <br />OWNER MAILING ADDRESS: sTREET -39 f S N� r.r,� �.1� �. <br />� p 7 <br />CITY � ✓i' (� L. .`- � % _ STATE �,'ti �-I ZIP p L� L'� <br />OWNER PHONE: Z S S Z 2 OWNER EMAIL: /U {`r <br />CONTRACTOR NAME: � U' • � � � �,�,1 c= `7 � �,` r�1 ( (U (� <br />CONTRACTOR ADDRESS: srReer Z�jC � S/N �'L J`r1��� � �'! � <br />CITY S��`% I L STATE t1! � ZIP Jr��L'� <br />CONTRACTOR PHONE: ZO �j �� 3 G % 7 7� CONTRACTOR EMAIL: y0 �- �/ % ZG' _�` �;/ C1/ �� /i/� j L. C'c %'� <br />CONTRACTOR LIC. #(REQUIRED): SUV�j -� i,�/� •� C. b CITY OF EVERETT BUSWESS LIC. #(RECIUIRED): <br />PRIMARY CONTACT: ❑ OWNER CONTRACTOR ❑ OTHER (Please Specify) <br />CONTACT NAME: CONTACT PHONE: 2� � �--��� 7Z � '7-c�� c��Z `J� 7 ZG <br />�li� I l�/� ��� 1J�•2 l L� CONTACT EMAIL: i�C Z�f 7 7 �'S 6�J%�� Ej n'l �4i L. C� G~• <br />AGREEMENT: The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title <br />l4 Water and Sewer or such other rules and regulations now existing or which may be established from time to <br />time. The applicant further agrees, as a condition precedenf to receiving service that the utilities division shall have <br />the righi at any time, without notice, to shut off or turn on the water supply for repairs, construction, and <br />nonpaymenf of charges or f ny other reasonable cause. I am the owner, or 1 am aufhorized by the owner of this <br />property to perform the� rk for hich application is made, and 1 comply with the State Contractors Law 18.27 <br />RCW and 296.200A W�AC. <br />:�'� Z� Z o <br />Date <br />City of Everett Official Use Only <br />FEE <br />�^ � <br />U <br />PERMIT # <br />U �O� � (/b� <br />(Revised 10/12/2015) <br />