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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: <br /> IF APPLICABLE: ❑ OUTSIDE CITY LIMIT ❑ BUILDING AREA SF ❑ LOT# <br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL <br /> CHANGE OF USE? ❑NO ❑YES, FROM TO <br /> UTILITY APPLICATION INFORMATION <br /> SEWER(check all that apply) WATER(check all that apply) <br /> JN,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 /> WNER 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: STREETj U Gf --seV <br /> CITYl /�. STATE `� zip � , <br /> CONTRACTOR PHONE-71-7 <br /> CONTRACTOR EMAIL: <br /> CONTRACTOR LIC.#(REQUIRED): r y r�� � / CITY OF EVERETT BUSINESS LIC.#( EQ J `) <br /> PRIMARY CONTACT: ❑OWNER ❑ CONTRACTOR ❑ OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: <br /> CONTACT EMAIL: <br /> AGREEMENT.The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title City of Everett 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, as a condition precedent to receiving service that the utilities division shall have r <br /> the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and <br /> nonpayment of charges or for any other reasonable cause.1 am the owner,or I am authorized by the owner of this <br /> property to for which application is made,and I comply with the State Contractors Law 18.27 PERMIT# <br /> RCW afi�296.200A W U <br /> Owner/Authorize Agent Signature Date (Revised 10/121212015) <br />