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WATER / SEWER UTILITY APPLICATION <br />� CITY OF EVERETT PERMIT SERVICES ' l%� S/2 —40, j <br />3200 CEDAR STREET, EVERETT, WA 98201 �?_8_/s <br />(P) 425-257-8810 � Fl�C 425-257-8857 �(E) everetteps@everettwa.gov � www.everettwa.govlpermits <br />:OJECT AODRESS: <br />APPLICABLE: <br />1�LDING TYPE: <br />{pNGE OF USE7 <br />PROJECT SITE INFORMATION <br />❑ OUTSIDE CITY LIMITS ❑ BUILDING <br />IIDSPR-DETACHED ❑SFR-ATTACHED ❑DULEX QIJULTI-FAMILY-#Of UNITS' <br />fRJ NO ❑ YES, FROWi <br />TO <br />O LOT � <br />❑COMMERCIAL ❑INDUSTRIAL <br />UTILITY APPLICATION INFORMATION <br />SEWER (check all ihat apply) WATER (check all that apply) <br />l�'SIDE SEVJER REPAIR ❑ NEN! WATEFi SERVICE INSTnLIATION <br />I� SIDE SEWER ALTERATION ❑ COMPLETE SERVICE ❑ MGTER ONLY <br />❑ NEW SIDE SEWER INST�LLATION SERVICE / METER USE. <br />❑ INSTALL BACKW�TER VAWE (outs�de Ihe hudding) ❑ SFR <br />❑ SIDE SEWER CAP-OFF ❑ MULTI•FAMILY - It OF UNRS _ <br />❑ SIDE SEWER RECONNECTION ❑ COMMERCIAL <br />MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE / SiZE (circle desved size) <br />❑ I AM DECLINING MULTIPLE �OMESTIC WATER SERVICES FOR ❑ DOMESTIQ 3l4", 1'�, 2". OTHER� <br />MY MULTI-FAr�1ILY DEVELOf'MENT UNDER SINGLE OWNERSHIP ❑ �{�RIGATION� 3/4", 1", 2". OTHER <br />❑ I AM OPTING TO INSTALL MJLTIPLE DOMESTIC WATER ❑ FIRE�. � t". 2". 4". 6", 8". OTHER <br />SFRVIC[S FCR MY MULT6f�MILY DEVELOPMENT UNDER ❑ DOMESTIC/FIRE COMBO 1", 2", OTHER. _ <br />SIIJGL[ OWNFRSHIP. FILC OUT REVERSE SIDE OF THIS FORM. <br />AGREEfdENT Tne unCersignrd appGwnl a9recs Io compry �mtn a�l prowsions ol lhe Evemtt M1"un¢rpal CnCe i�tic <br />ta 1Nale� an0 Se:reror sucn olher rufes anAregulahons no�v existmg or a�hich may be eslabhshed Irom hme to <br />hme Tne apphcani lutlher ag�ees, as a rontl�bon preceCenf (o recervmg service IOaI Ihe ufAdies dmsion shail have <br />!he nght at any hme, �mf�ouf nofice, lo snuf oH or Nm on Me wala suppylor repa�rs. co�stn�chon, antl <br />no��O�Ymenf o� charges or7or any ofher reason�6le cause I am (he o�vne�, or I am auf�onle4 hy fhe owner o/ Ihis <br />pmpe�ly lo pedonn fhe rvork lor wh�ch apphcatron is made, and I conply w•Ih !OC State Conirattors La�v 18 27 . <br />RCbV a�d 29��4 �A <br />9/9//5 <br />Agent Signatutc <br />Date <br />ary or everert vrnoa� we �nry <br />F[[ O <br />-3�0 <br />PERMIT tJ ' <br />U i � � � r oV-� <br />(Revised f0/12QOi5) <br />