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/ WATER ■/ SEWER UTILITY APPLICATION CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P)425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECTADDRESS: IF APPLICABLE: ❑OUTSIDE CI LIMITS ❑ BUILDING AREA SF ❑ LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? NO ❑YES, FROM TO UTILITY APPLICATION INFORMATION SEWER(check all that apply) WATER(check all that apply) ❑ SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION ❑ SIDE SEWER ALTERATION ❑ COMPLETE SERVICE ❑ METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: INSTALL BACKWATER VALVE(outside the building) ❑ SFR ❑ SIDE SEWER CAP-OFF ❑ MULTI-FAMILY-#OF UNITS: ❑ SIDE SEWER RECONNECTION ❑ COMMERCIAL MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE: (circle desired size) ❑ 1 AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR ❑ DOMESTIC: 3/4", 1", 2", OTHER: MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ IRRIGATION: 3/4", 1", 2", OTHER: ❑ 1 AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑ FIRE: 11., 2", 4", 6", 8", OTHER: SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER ❑ DOMESTIC/FIRE COMBO: 1", 2", OTHER: SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. CONTACT INFORMATION OWNER NAME: 1? TENANT NAME(If Commercial): OWNER MAILING ADDRESS: sTREET CIN STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: 1A KA CONTRACTOR ADDRESS: STREET V ClrySTATE A • ZIP CONTRACTOR PHONE: CO TRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSIN LIC.#(REQUIRED) O PRIMARY CONTACT: ❑OWNER ❑ CONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: • CONTACT PHONE: CONTACT EMAIL: ` c AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal dode Title City of Ever t Official Use Only 14 Water and Seweror such other rules and regulations now existing or which may be established from time to FEE time. The applicant further agrees, a con i. precedent to receiving service that the utilities division shall have the right at any ' e,w' t notic ,to shut off o turn on the water supply for repairs,construction, and J©•�/ nonpayment ch r s or or arl other reasona le cause.I am the owner,or I am authorized by the owner of this v property to p or he wo hich applicatio is made,and I comply with the State Contractors Law 18.27 PERMIT# RCW and 29 200 WAC caner/Authoriz gent Sig ature Date (Revised 10/1212015)