Laserfiche WebLink
• <br /> WA ER I SEWER UTILITY(' APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> (P) 425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: 1 <br /> IF APPLICABLE: ❑ OUTSIDE CITY L MITS ❑ BUILDING AREA SF ❑ LOT# <br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL <br /> CHANGE OF USE? YNO ❑YES, FROM TO <br /> UTILITY APPLICATION INFORMATION <br /> SEWER(check all that apply) WATER(check all that apply) <br /> ❑ SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION <br /> ❑ 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 /> ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑ FIRE: 1", 2", 4", 6", 8", OTHER: <br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER ❑ DOMESTIC/FIRE COMBO: 1", 2", OTHER: <br /> SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM <br /> CONTACT INFORMATION <br /> OWNER NAME: uV ' I I TENANT NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET <br /> CITY STATE ZIP <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR NAME: p tV&1A KA <br /> t� <br /> CONTRACTOR ADDRESS: STREET I/ <br /> CITYPvt� STATE A • ZIP <br /> CONTRACTOR PHONE: CO TRACTOR EMAIL: s <br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSIN LIC.#(REQUIRED): 0 <br /> PRIMARY CONTACT: ❑OWNER ❑ CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: ✓b Z <br /> CONTACT EMAIL: C c <br /> AGREEMENT The undersigned applicant agrees to comply with all provisions of the Everett Municipal 10e Title Cify of Evertqt Official Use Only <br /> 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to FEE <br /> time. The applicant further agrees,as'a conditign precedent to receiving service that the utilities division shall have <br /> the right at any time,w'thout notic4 to shut off or,,turn on the water supply for repairs,construction,and w " <br /> nonpayment f char 2s or or any'other reasonable cause.I am the owner,orl am authorized by the owner of this <br /> property to p oralhe wo r hich application is made,and I comply with the State Contractors Law 18.27 PERMIT# <br /> RCW and 29 200 WAC <br /> caner/AuthoriZ891gent Sig ature Date (Revised 10/12/2015) <br />