Laserfiche WebLink
41 <br /> WATER / SEWER UTUTY APPUCATION <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 /> PROJEECT SITIE INFORMATION <br /> F <br /> PROJECT ADDRESS: L6 , <br /> IF APPLICABLE: ❑OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT# <br /> BUILDING TYPE: ❑SFR-DETACHED E]SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL <br /> CHANGE OF USE? NO ❑YES, FROM TO <br /> UTOILETY AFFILECATI]CH INFORMATOOM_ <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 <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: <br /> SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORINT. <br /> I y�� CCONTACT131t`FORif16`ATIION <br /> p <br /> OWNER NAME: "iL � l IA (�� ` 'n� 1'rL 9 TENANT NAME (if Commercial): <br /> OWNER MAILING ADDRESS: STREET LAO <br /> CITY <br /> STATE ZIP <br /> 'OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR NAME: <br /> CONTRACTOR ADDRESS: STREET owl <br /> i <br /> CITY STATE WA o ZIP <br /> (CONTRACTOR PHONE: HQJ DIIACONTRACTOR EMAIL: I <br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSIN LIC.#(REQUIRED): D <br /> PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: 4(m1 (7 04V M <br /> s �� CONTACT EMAIL: l 'r6=�' I V_Iff� <br /> AGREEMENT The undersigned applicant agrees to comply with all provisions of the Everett Municipal ode 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 E E E <br /> time.The applicant further agrees, a con i" precedent to receiving service that the utilities division shall have ( <br /> the right at any " e,w" t not ic ,to shut off o tum on the water supply for repairs,construction, and l• <br /> nonpayment c r s or or anj other reason /e cause./am the owner,or I am authorized by the owner of this ��✓ — <br /> property to p o he wo hich applicatio is made,and I comply with the State Contractors Law 18.27 PERMIT <br /> # <br /> RCW and 29 200 WAC U <br /> wner/Authoriz gent Sig ature Date (Revised 10/1212015) 1 <br />