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1 <br /> WATER / SEWER UTILITY APPLICATION <br /> 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: 2. <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? YNO ❑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. ❑ 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: <br /> CONTRACTOR ADDRESS: STREET <br /> CITYPA"Iq�+ STATE V` • ZIP <br /> CONTRACTOR PHONE: CO TRACTOR EMAIL: kA • <br /> CONTRACTOR LIC.#(REQUIRED):.MW CITY OF EVERETT BUSI11-1 N LIC.#(REQUIRED): Q <br /> PRIMARY CONTACT: ❑OWNER ❑ CONTRACTOR ❑ OTHER(Please Specify) <br /> CONTACT NAME: • CONTACT PHONE: 5-6) <br /> I,IA Z <br /> / r11�j ��`� Y�� CONTACT EMAIL: J 04 <br /> � � � • � <br /> AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal dode Title City of Fver&lt Official Use Only <br /> 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to FEE <br /> time. The applicant further agrees, a con r' n precedent to receiving service that the utilities division shall have 6� <br /> the right at any ' e,w' t notic ,to shut off o turn on the water supply for repairs,construction, and <br /> nonpayment ch r s or or an other reasona le cause./am the owner,or I am authorized by the owner of this <br /> property to p or he wo hich applicatio is made,and/comply with the State Contractors Law 18.27 PERMIT# <br /> RCW and 29 200 WAC U M�_U <br /> y� <br /> caner/Authoriz gent Sig ature Date (Revised 10/1212015) v 1 <br />