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I WjER / SEWER UTILITY OPLICATION 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 www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: IMz IF APPLICABLE: ❑ OUTSIDE CITY 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) ❑ I 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: ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑ FIRE: 1", 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: TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET CITY STATE ZIP OWNER PHONE: S3V 3 OWNER EMAIL: CONTRACTOR NAME: �•`9`-�"�I� CONTRACTOR ADDRESS: STREET o 1 c / (/y CITY L4<0' /! STATE '25ZIP CONTRACTOR PHONE: CONTRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): `� CITY OF EVERETT BUSINESS LIC.#(REQUIRED)- PRIMARY CONTACT: ❑ OWNER CONTRACTOR ❑ OTHER(Please Specify) CONS NAME- CONTACT PHONE: Z Z ^ JCONTACT EMAIL: AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title City of Eve tial Use Only 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to FEE time. The applicant further agrees, as a condition precedent to receiving service that the utilities division shall have w Othe right at any time,without notic , s u o urn on the water supply for repairs,construction, and �� nonpayment of or for y other reasonabl cause.1 am the owner,or l am authorized by the owner of this 1. propert perform the ch application' made,and I comply with the State Contractors Law 18.27 PERMIT# RC nd 296.200A u l Wl lJ OwnedAu ent Si ature to (Revised 10/12/2015) y