808 105TH PL SE 2017-01-13 - Laserfiche WebLink

�/�� I�� ,�P�L��AT�� 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 BACKVI/ATER 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 with all provisions of the Evereft Municipal Code Title 14 Water and Sewer or such other rules and regulafions now existing or which may be established from time io time. The applicanl further agrees, as a condition precedent to receiving service ti�at the utilifies division shall have the right at any time, withouf notice, to shut o(f 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 fhe owner of this property to perform the wo�k for which application is made, and I comply with the Sfate Contractors Law 18.27 RCW and 296.200A WAC�, � ��.- �� ; i'/.1 �'/i � Owner/Authorized Agent Signature Date City of Everetf Official Use Only FEE ��-� �✓��,"f. PERMIT # U � � � � --- ,� i ,:� V� r.-, (Revised 10/12/2015)