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WATER / SEWER UTILITY APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> (P)425-257-8810 FAX 425-257-8857 1 (E) everetteps@everettwa.gov www.everettwa.gov/permits <br /> PRQJ)EC'T SITE`;INFORMATION <br /> PROJECT ADDRESS: <br /> IF APPLICABLE: ❑OUTSIDE CITY LIMITS ❑ BUILDINGAEA EA SF ❑LOT# <br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY#OF UNITS: COMMERCIAL ❑INDUSTRIAL <br /> CHANGE OF USE? NO ❑YES, FROM TO <br /> UTILITY,'APPLICA .1OW INFORMATION _ <br /> - .:- <br /> SEWER <br /> -..__. _:..,. .. -. _ - _. .. <br /> R(check all that apply) WATER(check all that apply) <br /> ❑SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION <br /> �ZJ SIDE SEWER ALTERATION ❑ COMPLETE SERVICE ❑METER ONLY <br /> ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: <br /> ❑ INSTALL BACKWATER VALVE outside the building) ❑SFR <br /> ❑SIDE SEWER CAP-OFF ❑MULTI-FAMILY-#OF UNITS: <br /> ❑ SIDE SEWER RECONNECTION ❑COMMERCIAL <br /> MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE: (circle desired size) <br /> ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR ❑ DOMESTIC: 3/4", 1", 2", OTHER: <br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ IRRIGATION: 3/4", 1", 2", OTHER: <br /> ❑TI AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑ FIRE: 1", 2", 411, 611, 8", OTHER: i <br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER ❑ DOMESTIC/FIRE COMBO: 1", 2", OTHER: j <br /> SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. <br /> CONTACT I)AIIFORNiATIO <br /> OWNER NAME: &71LI 69 9 TENANT NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET O �OU `2ftr� W <br /> crN �' ' Uj/ STATE ZIP <br /> OWNER PHONE: OWNER EMAIL: 7U (IJ6 S-r CCS <br /> i <br /> CONTRACTOR NAME: G4� <br /> CONTRACTOR ADDRESS: -STREET <br /> CITY STATE ZIP <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED): <br /> PRIMARY CONTACT: OWNER ❑CONTRACTOR ElOTHER(Please Specify) <br /> CONTACT AME: <br /> AME: / CONTACT PHONE: <br /> C U 71� CONTACT EMAIL: eo <br /> AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title City of Everett Official Use Only <br /> 14 Waterand Seweror such other rules and regulations now existing orwhich may be established from time to FEE <br /> time.The applicant further 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 water supply for repairs,construction,and <br /> nonpayment of charges or for any otherreasonable cause.i am the owner,ort am authorized by the owner of this <br /> property to perform the work for which application is made,and I comply with the State Contractors Law 18.27 PERMIT# <br /> RC and 2g..2 A WAC. <br /> Owner/ uthorized A ent Sig tire Date (Revised 10/12/2015) <br /> 4 <br />