1901 16TH ST 2018-01-02 MF Import

WATER / SEWER UTILITY APPLICATION CITY OF EVERETT PERMIT SERVICES LJ 151 z - D y) 3200 CEDAR STREET, EVERETT, WA 98201 / a -a9 -15 (P) 425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov ; www.evereth&ja.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: / 1 I o(O ( 1 6—Al S— _ IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT # BUILDING TYPE: ©SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI -FAMILY-# OF UNITS:_ ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? Au NO ❑ YES FROM .- _ TO UTILITY APPLICATION INFORMATION SEWER (check all that apply) I WATER (check all that apply) I SEWER REPAIR (❑ NEW WATER SERVICE INSTALLATION ❑ SIDE SEWER ALTERATION I ❑ COMPLETE SERVICE ❑ METER ONLY ❑ NEW SIDE SEWER INSTALLATION ❑ INSTALL BACKWATER VALVE outside the building) ❑ SIDE SEWER CAP -OFF ❑ SIDE SEWER RECONNECTION MULTIPLE DOMESTIC WATER SERVICES REQUEST ❑ 1 AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR MY MULTI -FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP ❑ 1 AM OPTING 10 INSTALL MULTIPLE DOMESTIC WATER SERVICES FOR MY MULTI -FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. SERVICE / METER USE: ❑ SFR ❑ MULTI -FAMILY -# OF U ❑ COMMERCIAL WATER SERVICE TYPE / SIZE: (circle desired size) ❑ DOMESTIC 3/4", 1", 2", OTHER ❑ IRRIGATION: 3/4", 1", 2", OTHER. ❑ FIRE: 1", 2", 411, 6", 8". OTHER. ❑ DOMESTIC/FIRE COMBO: 1", 2", OTHER: CONTACT INFORMATION OWNER NAME: ), c, r i c- Lj u,4L 1,.1 TENANT NAME (if Commercial): OWNER MAILING ADDRESS: STREET Igo t G -r s cm ue1e'1 :r.:n i„/•7 zip 01$,20 OWNER PHONE: OWNER CONTRACTOR NAME: S u-rL\ LveS ttEMAIL, r 14 e', efS S.,L. CONTRACTOR ADDRESS: STREET I- an SC•irr) STATE 4-,7 zm ySS/o.d CONTRACTOR PHONE: '1O6 - 93�- 177 CONTRACTOR EMAIL: CONTRACTOR LIC. #(REQUIRED): _s"oo-r"wP071C6 ICITY OF EVERETT BUSINESS LIC. #(REQUIRED): - (C, D 3 PRIMARY CONTACT: ❑ OWNER ONTRACTOR ❑ OTHER (Please Specify) CONTACT NAME: Z_p 1nvi, swl IT k,\ CONTACT PHONE: CONTACT EMAIL: AGREEMENT, The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title 14 Water and Sewer or such other rule s and regulations now existing or which may be established from time to time. The applicant further agrees, as a condition precedent to receiving service that the utilities division shall have the right at anytime, without notice, to shut off or turn on the water supply for repairs, construction, and nonp+ymenl of charges or for any otherreasonable cause. I am the owner, or I am authonzed by the owner of this property to perform the work for which application is made, and I comply with the State Contractors Law 18.27 RCW and 29820hA WAC _ Agent Signature Date City of Everett uniciat use omy FEE �V a PERMIT # (Revised 1011212015)