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ATER 4 SEWER UTILITY9PPUC A ION <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 />UTIILOTYAPPLL[IOATION OINFORMAITOOM <br />SEWER (check all that apply) <br />WATER (check all that apply) <br />❑ SIDE SEWER REPAIR <br />❑ NEW WATER SERVICE INSTALLATION <br />❑ SIDE SEWER ALTERATION <br />❑ COMPLETE SERVICE ❑ METER ONLY <br />❑ NEW SIDE SEWER INSTALLATION <br />SERVICE / METER USE: <br />INSTALL BACKWATER VALVE outside the building) <br />❑ SFR <br />❑ SIDE SEWER CAP -OFF <br />❑ MULTI -FAMILY-# OF UNITS: <br />❑ SIDE SEWER RECONNECTION <br />❑ COMMERCIAL <br />WATER SERVICE TYPE / SIZE: (circle desired size) <br />❑ DOMESTIC: 314", 1", 2", OTHER: <br />MULTIPLE DOMESTIC WATER SERVICES REQUEST <br />❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR <br />MY MULTI -FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. <br />❑ IRRIGATION: 314", 1", 2", OTHER: <br />❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER <br />❑ FIRE: 1", 2", 4", 6", 8", OTHER: <br />SERVICES FOR MY MULTI -FAMILY DEVELOPMENT UNDER <br />❑ DOMESTICTIRE COMBO: 1", 2", OTHER: <br />SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. <br />CONTACT 9NFOfRU�'1iATIiON <br />OWNER NAME: TENANT NAME (If Commercial): <br />OWNER MAILING ADDRESS: STREET <br />CITY STATE Zip <br />OWNER PHONE: <br />OWNER EMAIL: <br />CONTRACTOR NAME: In`,, <br />Y <br />CONTRACTOR ADDRESS: STREET ll� ll �° <br />6� <br />CITY STATEIVA ZIP <br />CONTRACTOR PHONE: <br />CO TRACTOR EMAIL: <br />a �, <br />0/1 <br />IN LIC. #(REQUIRED <br />CONTRACTOR LIC. #(REQUIRED): <br />Lki. aI <br />CITY OF EVERETT BUS <br />PRIMARY CONTACT: ❑ OWNER ❑ CONTRACTOR ❑ OTHER (Please Specify) <br />CONTACT NAME: <br />CONTACT PHONE: II <br />2,b "' 911 <br />CONTACT EMAIL: ' <br />11 <br />a <br />s <br />AGREEMENT. The undersigned applicant agrees to comply with all provisions of the Everett Municipal dode Title City of Ever t Official Use Only <br />14 Waterand Sewer orsuch other rules and regulations now existing orwhich maybe established from time to FEE <br />time. The applicant further agrees, a con precedent to receiving service that the utilities division shall have /�Q <br />Q, �� <br />the right at any ' e, w' t notf , to shut off o turn on the water supply for repairs, construction, and <br />nonpayment ch r s or oran otherreasona le cause./ am the owner, or l am authorized by the ownerof this <br />property top or e wo hich applicatio is made, and l comply with the State Contractors Law 18.27 PERMIT # <br />RCW and 29 200 WAC [uno2)—ob q . I <br />wnerlAuthoriz gent Sig Lure Date (Revised 1011212015) <br />