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1 <br /> ATER 9 SEWER UTILITAPpUCATION <br /> 15 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 I www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: <br /> IF APPLICABLE: ❑ OUTSIDE CITY LIMITS BUILDING AREA SF ❑ LOT# <br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX []MULTI-FAMILY-#OF UNITS. ❑COMMERCIAL ❑INDUSTRIAL <br /> =CHANGE OF USE? qkN0 ❑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. <br /> 11 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: TENANT NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET <br /> CITY STATE ZIP <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR NAME: B A <br /> CONTRACTOR ADDRESS: STREET j II , ,q" tr1 1 'q� <br /> d o ZIP lot N - <br /> CITY STATE <br /> CONTRACTOR PHONE: 101011ICONTRACTOR EMAIL: I Q 6J o � ! <br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINE LIC.#(REQUIRED): <br /> PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR ❑ OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: un <br /> P ' <br /> CONTACT EMAIL: <br /> AGREEMENT.The undersigned applicant agrees to comply with all provisions of the Everett Municipal Ide Title City of Ever6lt Official Use Only <br /> 14 Water and Sewer or such other rules and regulations now existing or which maybe established from time to FEE <br /> time.The applicant further agrees, a condi precedent to receiving service that the utilities division shall have ^ W <br /> the right at any, e,w' t notic ,to shut off o tum on the water supply for repairs,construction,and <br /> nonpayment ch s or or an other reasona le cause.I am the owner,or I am authorized by the owner of this _ <br /> property top or <br /> -w <br /> wo hich applicatio is made,and l comply with the State Contractors Law 18.27 PERMIT# <br /> RCW and 29 200 WAC <br /> Ct_ DWI,, <br /> caner1Authoriz gent Sig Lure Date (Revised 10/1212015) <br />