10510 10TH DR SE 2017-01-13 - Laserfiche WebLink

Wf�°1��I1 ��Y19�I� U 1 ��.�� I�Pi��iA��oN CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P) 425-257-8810 � FAX 425-257-8857 �(E) everetteps@everettwa.gov � www.everettwa.gov/permits UTILITY APPLICATION INFORMATION SEWER (check all that apply) WATER (check all that apply) SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION ❑ SIDE SEWER ALTERATION ❑ COMPLETE SERVICE ❑ METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE / METER USE: ❑ INSTALL BACKWATER VALVE (outside the building) ❑ SFR ❑ SIDE SEWER CAP-OFF ❑ MULTI-FAMILY -# OF UNITS: ❑ SIDE SEWER RECONNECTION ❑ COMMERCIAL MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE / SIZE: (circle desired size) ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR ❑ DOMESTIC: 3/4", 1", 2", OTHER: MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ IRRIGATION: 3/4", 1", 2", OTHER: ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑ FIRE: 1", 2", 4", 6", 8", OTHER: SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER ❑ DOMESTIC/FIRE COMBO: 1", 2", OTHER: SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. AGREEMENT: The undersigned applicant agrees to comply wifh all provisions of the Everett Munrcipal Code Title 14 Water and Sewer or such other rules and regulations now existing or which may be estahlished from time to time. The applicanf further ag�ees, as a condition precedent to receiving service that the utilities division shall have the right at any iime, without notice, to shut off or turn on the water supply for repairs, construction, and nonpayment of charges or for any other reasonable cause. 1 am the owner, or I am authorized by the owner of fhis property to perform the work for which application is made, and I comply with the State Contractors Law 18.27 RCW and 2 6.200A W� - 1,��,� � /1 � Owner/Authorized Agent Signature Date City of Everett Official Use Only FEE �— PERMIT # U��(2--b��'� (Revised 10/92/2015)