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. i <br />WATER / SEWER UTILITY APPLICATION <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.J' � �j l �''���G l� ���"�i�%� <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 />NAME: L�G��� <br />MAILING ADDRESS: <br />PHONE: �.Z�'- <br />RACTOR NAME: , ( <br />RACTOR ADDRESS: <br />RACTOR PHONE: . <br />RACTOR LIC. #(REQUI <br />CONTACT INFORMATION <br />� ,� r�� TENANT NAME (If Commercial): <br />STREET ! � ��< � ��`� �� = "�`'- �G�. <br />CITY !'f��W ���< l� � /� STATE �I,/a/ � ZIP � <br />�`�1 "' � Z� C OWNER EMAIL: l��l�G- �� C��G�'�� /�<. �"�r G' <br />STREET <br />CITY <br />STATE ZIP <br />�R EMAIL:, <br />� CITY OF EVERETT BUSINESS LIC. #(REC2UI <br />PRIMARY CONTACT: �OWNER ❑ CONTRACTOR ❑ OTHER (Please Specify) <br />CONTACT NAME: � CONTACT PHONE: ��1-�- � �-�/�—/�'G� � <br />�5� ��`�C lj,l�� <br />CONTACT EMAIL: ��� � s,�- ������ � _ C' �� <br />AGREEMENT. The undersigned applicant agrees to comp/y with all provisions of the Everett Municipal Code Title City of Everett Official Use Only <br />14 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 precedent to receiving service that the utilities division shall have FEE � � <br />the right at any time, without notice, to shut off or turn on the water suppty for repairs, construction, and ;� ��EJ �� <br />nonpayment of charges or for any other reasonab/e cause. I am the owner, or I am authorized by the owner of this <br />property to pertorm the work for which app de, and I comply with the State Contractors Law 18.27 PERMIT # <br />RCW and 296.2Q9A�Dl A . ' � <br />�i -�l '�U �/� U � � � �f � (1"� �� <br />� Owner/Authorized A nt Signature Date (Revised 10/12/2015) <br />� <br />