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WATER / SEWER UTlLITY APPLICATION <br /> CITY OF EVERET7.PERMIT SERVICGS <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> (P) 425-257-8810 � FAX 425-257-8857 � ([) everetteps@everettwa gov � �+nvw.everethva gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECTADDRESS: ��O � f � , T ' Z <br /> fF APPI.ICABLE: G OUTSIDE CiTY LIMITS ❑ BUIL,.ING AREA SF ❑ LOT k <br /> BUII.OING TYPE: ❑Sf R-DETHCH[D ❑SFR-ATTACH[D ❑DULFX ❑MULTI-FAh�llLY-#OF UNITS_ ❑COPdMEF2Clf�1. ❑INDUSTRIAL <br /> CHANGE OF USE? � Nn ❑ YES. FROM TO <br /> � UTILITY APPLICATION INFORMATION <br /> SE7VER (check all uiat apply) WATER (check all that apply) <br /> ❑ SIDF SEWER REPAIR ❑ NEW WATER SERVIC� INS7ALlATION <br /> � SID[ S[WEF ALTf'_P.ATION ❑COtdPL[TE SERVICE ❑ Ir1ETER O�'JI.Y <br /> ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USc <br /> L+S INSTALL BACKWATER VALVE(outside the builoing) ❑ SFR <br /> ❑ SIDE SEWER CAP-OFF ❑ MULT6FAMILY-#OF UNiTS __ _ <br /> ❑ SIDE SFWER RECONNECTION ❑COMMERCIAL <br /> MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE!SIZE: (arcie des�rea s¢e1 <br /> ❑ I AM DECLINING MULTIPLE DO�A[STIC VJATEP, SERVICES FOit ❑ DOWESTIC. 3/4". 7", 2". OTHER <br /> tdY h1ULTl-FAMILY DEVELOPMENT UNDER SINGLE OW�JERSHIP ❑ IRRIGATION. 3/4", 1", 2". OTHER <br /> ❑ I AM OPTING TO INSTALL fdULTIPLE DOMESTIC WATER ❑ FIRE t". 2", 4". 6'�, 8". OTHER. <br /> SERVICES FOR PdY MULTI-FAMILY Df_VELOPPl�NT UNDER ❑ DOMESTIC/FIRE COP�180 1". 2" OTHFR <br /> SINGLE OWN[RSHIP FILL OUT REVERSE SIDE OF THIS FORM. <br /> CONTACT INFORMATION <br /> OWNER NAME: Q.V 67'\ ��L V�6\�' TENANT NAME U!Commerciaq: <br /> OWNER MA�LING ADDRESS: sraEEr � � .O ✓[ �l '�^ �JT�(��'. <br /> r,irv � sr>�E Z,� <br /> OWNER PHONE: � - � OWNER EMAIL: <br /> CONTRACTOR NAME: , 5 Nt �� I `Va-�/ _ �- � !'7�1 (i� �-(� <br /> CONTRACTOR ADDRESS: ��rr.r:er [p I/ / �GC-YGt�I'YtLL_ �/ 'G <br /> ❑tt 7Jl//f—� S�Aif (/vv� Ziv . ��U� <br /> CONTRACTOR PHONE: Z- 'O/Z�j CONTRACTOR EMAIL: �o�Yv7 /1�1 �C. -J G IY7 - <br /> CONTRACTOR LIC. k(a[QUIaED): I v /r� �I� Ol � qTY OF EVERETT BUSINESS IC.#(REOUIReDY �S� S�� <br /> PRIMARY CONTACT: ❑ OWNER CONTRACiOR ❑ OTHER (Please Speafy) _ _ <br /> CONTACT NAME: CONTACT PHONE: L�Z. _ � -O�Z � <br /> 2-n L'T l�� CONTACT EMAIL: <br /> �GREEWENT Tne u�Qe��gned appli��nf�grees fo comply wdh 3�I piwaions o/Ihe Evereft M1!umapal Code TRIe Cdy o(Everelf OlGcia�Use Only <br /> iJ Wafei a��tl Sen�er or such olhei mles and mgulabons rmv e+ishng o�which may be eslaCiished Imm hme lo FEE O <br /> Gme 7he apphr.anf lurtne�agrees. as a rondd�on precedenf lo receivmg servme Ihat Ihe uhi�Ges drva:en snall Aave � �,('� 10 <br /> fhe ngh!af any Gme,wdhouf nolice.fo shut ofl or fum on the waler supply lor repairs, conshucfron,antl �v � <br /> no�paY�� �h��9es lor any ofher reasonable cause �am Ihe oroner,oi I am aufhonzetl Uy Ihe oroner o�1�is � <br /> prcpe,/y pe ! Ihe�vo !or which apphpa6on is maCe,and I comply ivdh I�e Slafe Con(,acfors Law iB 27 pE RN11T# <br /> � RCV�a d296 OAWAC <br /> � � 1 - � � s U1� 2-ODI <br /> OwnedAu nLSigwturc Da�c (Revrsed 10�7?12015,i <br />