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W�ER / SEWER UTILITY �PLICATION <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 />PROJECTADDRESS: �=��/Z_ ��-'��'� �'�T��C�F'�.� �t/f'7S�{�•_ �/ir,.. 'J��L61 <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? � N� ❑ 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 />� <br />OWNER NAME: ��� �" �,i4•�(<; �li_ TENANT NAME (If Commercial): <br />OWNER MAILING ADDRESS: sTREEr �Z 2- � Z- 1� �'� ��I �l'� <br />� ;-(/���� CITY V✓/ � STATE ZIP �Ci� ,l'�, ( <br />OWNER PHONE: OWNER EMAIL: <br />CONTRACTOR NAME: ' /.�,,;%' <br />CONTRACTOR ADDRESS: sTREeT � � � ' {/ /�`";SL�� � tJ � <br />JT L, � <br />CC`� �C�CIn' pTATE �L /4!�ZIP <br />CONTRACTOR PHONE: CONTRACTOR EMAIL: <br />CONTRACTOR LIC. #(REQUIRED): ��� Sv�tTi�(/�/"�'-�� !� CITY OF EVERETT BUSINESS LIC. #(REQUIRED): �� ��•�� <br />PRIMARY CONTACT: ❑ OWNER ❑ CONTRACTOR ❑ OTHER (Please Specify) <br />CONTACT NAME: CONTACT PHONE: `;'� � �� '��, �' <br />n <br />�P�j/� �7 ,✓lc�, V CONTACT EMAIL: <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 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 <br />the right at any time, without notice, to shut off or turn on the water supply for repairs, construction, and <br />nonpayment of charges or for any other reasonable cause. 1 am the owner, or I am authorized by the owner of this <br />property to pertorm the work for which application is made, and 1 comply with the State Contractors Law 18.27 <br />RCW and 296.200A WAC. <br />Owner/Authorized Agent Sig <br />/ , <br />( 'y' � � � _ _ � � ; <br />Date <br />City of Everett Official Use ONy <br />FEE �O� <br />r- <br />PERMIT # <br />U f �ID ' � ��o <br />(Revised 10/12/2015) <br />