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WATER / SEWER UTILITY APPLICATION r CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P)425-257-8810 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: 2 1 2A rw 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? YNO ❑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: )I 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: OWNER EMAIL: CONTRACTOR NAME: CONTRACTOR ADDRESS: STREET CITY STATE • ZIP CONTRACTOR PHONE: CO TRACTOR EMAIL:WO I AAA V mm CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSIN LIC.#(REQUIRED): PRIMARY CONTACT: ❑OWNER ❑ CONTRACTOR ❑OTHER(Please Specify) CONTACT NAME: • CONTACT PHONE: 1 L1 501, Z 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. n precedent to receiving service that the utilities division shall have po the right at any ' e,w' t notic ,to shut off o turn on the water supply for repairs,construction, and nonpayment I ch r s or or an otherreasona le cause./am the owner,or 1 am authorized by the owner of this property top or he wo hich applicatio is made,and/comply with the State Contractors Law 18.27 PERMIT# RCWand29 200 WAC U FIDD —026 weer/Authoriz gent Sig ature Date (Revised 10/12/2015)