2015 MONROE AVE 2016-01-01 MF Import

WATER / SEWER LlTILITY APPLICATION CITY OF [V[RETT PERMIT SERVICES Ui5�� -o y3 3200 C[DAR STREET, EV=RETT, WA 98201 //��/S (P) 425-257-8810 � FAX 425-257-8857 � (E) everetteps@everettwa.gov � ww�.v.everethva govlpermits PROJECT SITE INFORMATION PROJECT ADORESS•• � !5 I� YY101�'�J`Q- `�'� v v "03 IF APPLICABLE: ❑ OUTSIDE GITY LIMI7S ❑ �UILDING AREA SF ❑ LOT# BUILDINGlYPE: OSFR-DETACHED OSFR-ATTACIihD ❑DULER OMUITI-FAMILY-#OFUNITS_ OCOMIJERCIAL ❑INDUSTRIAL CHANGE OF USE? ❑ NO �YES. FROM TO UTILITY APPLICATION INFORMATIOPI SEWER (check all ihat apply) WATER (check all that apply) �SIDE SEJJER REPAIR ❑ NEW WATER SERVICE INSTF�LLATION �� ❑COMPLETE SERVICE ❑ METER ONLV ❑ SIDE SEWER ALTERATION ❑ NEW SIDF SEWER INSTALIATION SERVIGE I MET[R USE� ❑ INS�ALL B�CKWAT[R VAWE(outsde the twld�ng) ❑ SFR � SIDE SEWER C/1P-0FF ❑ MULT6fAIdILY-#OF UNITS. ❑ SIDF SEWER RECONNECTION ❑CO�v1MERCIAL MULTIPLE DOMESTIC WATER SERVICES RECUEST WA7ER SERVICE TYPE I SIZE (circie desired s¢e) 0 I AM DECLINING MULTIPLE DON�[�TIC WATER SGRVICES FOR ❑ DOMESTIC. 3l4", i". 2", OTHER tdY MULTI-FAMILY DEVELOPMEN?UNDER�INGLE OWNERSHIP. ❑ IRRIGATION�. 3!a", 1", 2", OTHER. ❑ I AM OPTING TO INSTALL MULTIPL[ DOMESTIC WATER ❑ FIRE. r, 2', a", 6", 8", OTHER. SERVICES FOR MY MULTI-FAMILY DEV[IOPMENT UNDER ❑ DOMESTICIFIRF COMBO. 1". 2", OTNER SINGLE OWNERSHIP FILL OUT REVERSE SIDE OF THIS FORM. CONTACT INFORMATION OWNER NAME: � S TENANT NAME(I1 Commercial�: OWNERMAILINGADDRESS: srae�r ��S OY� /��"—`-' ��ry SraT�tti :�� Zo OWNER PHONE: OWNER FMAIL: CONTRACTOR NAME: �� O O r CONTRACTORADDRESS: serr.r O SS U W' ) � �L � .n4-I V pIT / /_ � w� I c-. ;,.,,� w�n Z�, - 1 � CONTRACTOR PHONE:20� Z S S �(D lY I CONTRACTOR EMAIL: CONTRACTOR LIC. #(RE�UiREJ): O� S G 1 1\ CITY OF EVERETT BUSINESS LIC.qIR[OUiREO): � �' PRIMARY CONTACT: ❑ OWNER �'CONTRACI�OR ❑OTHER(Plcase Spccily) — CONTACT NAME: ��0('g�_ CONTACI"PHONE: Z� 2 S S Z �/ CONTACT EMAIL: AGREEh'EA'T The un0er;•gned app�ican(agmes fo compiy wAh a�l prows:ons o!I�e Evemtl N,unrnpal Code TAIe C�ty ol Evemtt OHinal U5e Only f a Waler and Senr�or sucn o�her iules and regWabons now exaling e�a�nich may De esfablahetllmm hme fo FE� rt� time The ap0'��ant lurther agf s, as a rondihon pmce enl(o rcceiv�ng service fhal t�e ufdfhes drvismn shae have ��/�'V fhe nghf al any Lme,wdlr olice. lo shul ofl o�� on fhe��•al^.r�upPly for mpairs,conSVuchon,and V � non0aymenf ol c"aig� or any clher�s e[e '�u5e I am fhe owr^/.oN am aulhenzed Ey Ihe owner o(lhis property fo peAor�y! �co/A!or��'u[h �icahon�. r,�ade,antl I Comply•wlh fhe Sfafe ont�uclors Law 78.27 pERMiT it RCW and 296 2/� wnc I�1 r � �'��-- �� 5 � � OwnerfLiulhoriz gent Signaturc Date (Rev�sed 10�12R015)