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' WATER / SEWER UTILITY APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES U�S/2 — pa� <br /> 3200 CEDAR STREET, EVERETT, WA 98201 /,� _/Ej--/S <br /> (P) 425-257-8810 � FAX 425-257-8857 � (E) everetteps@everettwa gov � wvr�v.everettwa.gov/permits <br /> � PROJECT SITE INFORMATION <br /> PROJECT ADORESS: I I I 4 P•�c � F'.[ A � <br /> IF APPUCABLE: ❑ OUTSID[CITY LRdITS ❑ BUILDING AREA SF ❑ LOT# <br /> BUILDING TYPE: ❑SFR•DETACNED ❑SFR•ATTACHED ❑DULEX ❑tJ�ULTi-FA1.71LVx OF UMTS L`7COMM[RCIAL OINDUSTRIAL <br /> CHANGE OF USE? � NO ❑ YES, FROM TO <br /> UTILITY APPLICATION INFORMATION <br /> SEWER (check all that apply) WATER (check all Ihat apply) <br /> �SIDE SEWER REPAIR ❑ NEW WATER SERVICG INSTALIl\TION <br /> O SIDE SEWER ALT[RAIION ❑ CONPI.ETE SERVICE ❑ M[TER ONLY <br /> ❑ NEW SIDE S[WER INSTALLATION SERVICElMETGR USE <br /> ❑ INSTAII BACKWATER VALVG(outs�de;he bwld�ng) ❑ SFR <br /> ❑ SIDE SE-WER CAP-0FF ❑ MULTI-PA1.1iLY-#OF UNITS <br /> � SIDL SEWER RECO4NECTION ❑CO�d�JERCIAL <br /> MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE (cvcle desired size) <br /> ❑ I�td D6CLINING MULTIPLE DOIdESTIC WAT[R SERVICES FOR ❑ DONESTIC: 3/a•, t", 2", OTHER <br /> MY MULTI-FAMILY DEVEI.OPMENT UNDER SINGLE OWNERSHIP ❑ IRRIG/1TION 3/4", 1", 2", OTHER� <br /> ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WAT6R ❑ FIRE. 1". 2", 4", 6", B". OTHER� <br /> SFRVIC[S FOR MY NULTI-FAMILY D[VELOPMENT UNpER ❑ DOh1[STIC/FIRF COIJ80. 1", Z", OTH[R <br /> SINGLE OWN[RSHIP. FILL OUT REVERSE SIDE OF THIS FORM. <br /> CONTACT INFORMATION <br /> OWNER NAME: TENANT NAME (If Commerciaq: Ga-tre� �,.c P e.,,f <br /> OWNER MAILING ADDRESS: sraeEr <br /> Cir+ Stni[ Dv <br /> OWNER PNONE� OWNER EMAIL: <br /> CONTRACTORNAME: vn�..� 1����..,�R , s <br /> CONTRACTOR ADDRESS: stne�� gJS S IS ��` 5� <br /> �.�,. S�..a4� :,,,�, ��l ;�� y8� "X <br /> CONTRACTOR PHONE: �U�—� S� ' S27U CONTRACTOR EMAIL� <br /> CONTRACTOR UC.#�keouueeo�� /RS��T��GS Y Z CITY OF EVERETT BUSINESS LIC.p(�tLOuiRfo): bS�z'Q'I <br /> PRIMARY CONTACT: ❑ OWN[R �CONTRACTOR ❑ OTHflR(Please Specdy) <br /> CONTACT NAME: CONTACT PHONE: �I7/ � �/7- 33�j <br /> �{�G/".n /�(��.K . CONTACTEMAIL: <br /> AGREEldENT The untlersi9^eC aDPl�canl agmes to comply iwth a��p�ovivo�s o�Me Evernn Mumapal Cotle Trtie Crty ol Evrsielf ONic�al Use Only <br /> 7a IYatcr and Seweror sucn olhcr rules and iegWahons now c�uhng or whxn may be eslabbshe0�mm hme to F�� <br /> 6me T�e apphca�f lurt�er agrees. as a ronORmn precetlenl to 2ce�vmg sernce flrel fhe v1Ad�e5 Orv�s�on slrali hare ^- � <br /> Ihe nqhf at any hme,wAhout nohce. fo shul oll o�tum on fhe ualer supOty lor repa�rs,consfruc(mn,and � /lo �� <br /> nonpayment of c�argrs or(or any ofber reasonaD!e cause I am Ihe owner,or I am aulhonretl0y Ne ownero(N�s -� <br /> propeAy fo peAortn Ihe�vork�or wn�ch appAwGon ia matle.and I compty�mfn fhe S�ale Contrac!ors La�v f 8 27 p[RMIT# <br /> 17CW and 29F 200A Y�jC � <br /> 75/-��--I-- �� �z��6�, s u 15 - D <br /> 0wncr" IAuthor�acd Agent Signature Uaie (Remsed 10/1?17015) <br />