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WATER / SEWER UTILITY APPLICATION <br />CITY OF EVERETT PERMIT SERVICES (J <br />l5/e—o22 <br />3200 CEDAR STREET, EVERETT, WA 98201 ( a-15-1 5 <br />(P) 425-257-8810 ( FAX 425-257-8857 1 (E) everctteps@everettwa gov I www.everettwa gov/permits <br />PROJECT SITE INFORMATION <br />PROJECT ADDRESS: <br />q �/ <br />I 1 [ I <br />IF APPLICABLE: <br />❑ OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT # <br />BUILDING TYPE: <br />❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI -FAMILY-# OF UNITS _ ❑COMMERCIAL ❑INDUSTRIAL. <br />CHANGE OF USE? <br />❑ NO ❑ YES, FROM _ TO _ <br />UTILITY APPLICATION INFORMATION <br />L <br />SEWER (check all tnat apply) <br />WATER (check all that apply) <br />SIDE SEWER REPAIR <br />❑ NEW WATER SERVICE INSTALLATION <br />SIDE SEWER ALTERATION <br />❑ COMPLETE SERVICE ❑ METER ONLY <br />❑ NEW SIDE SEWER INSTALLATION <br />SERVICE / METER USE. _ <br />❑ INSTALL BACKWATER VALVE outside the bLAchng) <br />❑ SFR �I <br />"- <br />❑ SIDE SEWER CAP -OFF <br />#OF UNITS - <br />❑MULTI -FAMILY -: . <br />❑ SIDE SEWER RECONNECTION <br />❑ COMMERCIAL <br />WATER SERVICE TYPE / SIZE. (circle desired size) <br />❑ DOMESTIC 3/4", 1", 2", OTHER - <br />MULTIPLE DOMESTIC WATER SERVICES REQUEST <br />❑ 1 AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR <br />MY MULTI-FAFAILY DEVELOPMENT UNDER SINGLE OWNERSHIP. <br />❑ IRRIGATION: 3/4", 1", 2", OTHER <br />❑ 1 AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER <br />❑ FIRE 1", 2", 4", 6", 8", OTHER, <br />SERVICES FOR MY MULTI -FAMILY DEVELOPMENT UNDER <br />❑ DOMESTICIFIRE COMBO. 1", 2", OTHER' <br />SINGLEOWNERSHIP FILL OUT REVERSE SIDE OF THIS FORM. <br />CONTACT INFORMATION <br />OWNER NAME: V <br />-4 -aS TENANT NAME (If Commercial)_ <br />� <br />OWNER MAILING ADDRESS: SfREEr O ( - Z (' a 40,l=yf/ <br />C 11), Sr.1rF ZIP <br />OWNER PHONE: <br />OWNER EMAIL: <br />CONTRACTOR NAME: <br />CONTRACTOR ADDRESS: <br />�F eaz ZIP <br />ur. <br />CONTRACTOR PHONE: 20(rr-5(-00 Q CONTRACTOR EMAIL: <br />qq <br />CONTRACTOR LIC. #(REQUIRED): Sv�1 W O G CITY OF EVERETT BUSINESS LIC. #(REQUIRED): 7 D <br />PRIMARY CONTACT: ❑ OWNER CONTRACTOR ❑ OTHER (Please Specify) <br />CONTACT NAME: <br />CONTACT PHONE: <br />CONTACT EMAIL: <br />p <br />AGREEMENT: The undersigned applicant agrees to comply with as provisions of the Everett Municipal Code Title <br />14 Water and Sewe• or such other rules and regulations now existing or which may be established from time to <br />time. The applicant mrther agrees, as a condition precedent to receiving service that the utilities division shall have <br />the right at any time, without notice, to shut off or turn on the wafer supply for repairs, construction, and <br />nonpayment of charges or for any other reasonable cause I am the owner, or I am authorized by the owner of this <br />properly to peA�rm the work for wni Ch app(Icaton is made, and I comply with the State Contractors Law 18.27 <br />RCW and;nti OA WA C � � 'I I <br />Owner/Authorized Agent <br />City of Everett Official Use Only <br />FEE V <br />°i <br />PERMITIf <br />-- <br />62Z <br />(Revised 10'1212015) <br />