Laserfiche WebLink
ATER 9 SEWER U ILITYOPP IUCATION <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 /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: ` C <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 /> FHANG7OF USE? NO ❑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: i", 2", 4", 6", 8", OTHER: <br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER ❑ DOMESTIC/FIRE COMBO: 1", 2", OTHER: J <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 /> ciTv sTicr=_ zlh <br /> OWNER PHONE: OWNER EMAIL: <br /> tA- <br /> CONTRACTOR NAME: piwk <br /> ®[ <br /> CONTRACTOR ADDRESS: STREET <br /> CITY + STATE AM a ZIP <br /> CONTRACTOR PHONE: CO TRACTOR EMAIL: <br /> CONTRACTOR LIC.#(REQU1RED): CITY OF EVERETT BUSIN 4LIC.#(REQUIRED <br /> PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: <br /> ✓ � � �G CONTACT EMAIL: <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 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 condi precedent to receiving service that the utilities division shall have O <br /> the right at any ' e,w" t notic ,to shut off o turn on the wafer supply for repairs,construction,and <br /> nonpayment ch r s or r an other reasona le cause.l am the owner,or I am authorized by the owner of this if <br /> property to p or e wo hich applicatio is made,and I comply with the State Contractors Law 18.27 PERMIT# <br /> RCW and 29 200 WAC p p <br /> caner/Authoriz gent Sig ture Date (Revised 10/12/2015) <br />