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VEER / SEWER UTUTYWPPLI CATION \ 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 I www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: IF APPLICABLE: ❑OUTSIDE CITY LIMITS ❑ BUILDINGAREA SF ❑ LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX []MULTI-FAMILY�OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE?_ NO ❑YES, FROM TO U ITOLOTIY APPUCATDON RMFOIRG�liATIOiP9 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) 111 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: V, 2", 4", 6", 8", OTHER: I SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER ❑ DOMESTIC/FIRE COMBO: 1", 2", OTHER: SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. CONTACT DNFOfRIMATIOIN OWNER NAME: TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET CITY STATE ZIP OWNER PHONE: OVVNER EMAIL: CONTRACTOR NAME: CONTRACTOR ADDRESS: STREET II V cN CITY a STATE VA ZIP 41 CONTRACTOR PHONE: LIQ59- CO TRACTOR EMAIL: ,p CONTRACTOR LIC.#(REQUIRED): 1 �, CITY OF EVERETT BUSIN 4 LIC.#(REQUIRED PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: CONTACT PHONE- CONTACT HONE: CON TACT EMAIL: MCI, yk & L ' - a 0 AGREEMENT..The undersigned applicant agrees to comply with all provisions of the Everett Municipal dode Title Cify of Ever t Official Use Only 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to FE E time.The applicant further agrees, a coni precedent to receiving service that the utilities division shall have the right at any, ' e,w' t noh ,to shut off o tum on the water supply for repairs,construction,and nonpayment ch s or or an otherreasona le cause.I am the owner,or l am authorized by the owner of this property to p or he wo hich applicafio is made,and I comply with the State Contractors Law 18.27 P ERM IT# RCW and 29 200 WAC U p � caner/Authoriz gent Sig ature Date (Revised 10/1212015) U t