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WATER I SEWER UTILITY APPL�UCC/ TON <br /> A /"/"!VILP.-'' <br /> CITY OF EVERETT PERMIT SERVICES <br /> t� 3200 CEDAR STREET, EVERETT, WA 98201 <br /> (P)425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov l www.everettwa.gov/permits <br /> _ _ _ _ __ - <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: 02-11 I S Hi?'n' ' IIF APPLICABLE: 0 OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT# <br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: DCOMMERCIAL ❑INDUSTRIAL <br /> CHANGE OF USE? ❑NO 0 YES, FROM TO <br /> UTILITY APPLICATION INFORMATION <br /> SEWER(check all that apply) WATER(check all that apply) <br /> $SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION <br /> ❑ SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY <br /> ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: <br /> ❑ INSTALL BACKWATER VALVE(outside the building) 0 SFR <br /> ❑ SIDE SEWER CAP-OFF 0 MULTI-FAMILY-#OF UNITS: <br /> ❑ SIDE SEWER RECONNECTION 0 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. 0 IRRIGATION: 3/4", 1", 2", OTHER: <br /> ❑ 1 AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER 0 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 /> X <br /> OWNER NAME: qclelien ectig.T.01 - TENANT NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET <br /> CITY STATE ZIP <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR NAME: /9/',5 'ESCt/E /cOTE?— <br /> CONTRACTOR ADDRESS: STREET f•75 ? e -RD 5 <br /> ciTY 71 C,F►r_ STATE (,J (-I•- ZIP 9 80(.1--) <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED): <br /> PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR ❑ OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: 213 ?)i-11- /ti V <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 h� <br /> time. The applicant further agrees, as a condition precedent to receiving service that the utilities division shall have (l <br /> the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and 41;30 <br /> nonpayment of charges or for any other reasonable cause.I am the owner, or l am authorized by the owner of this <br /> property to perform the work for which application is made,and I comply with the State Contractors Law 18.27 PERMIT# 6\ <br /> RCW and 296.200A WAC. U 1 r /�I Y r, <br /> .,`' ��►�•+•..- / I (jell I✓1 <br /> Owner/•u orized Agent Signature rate (Revised 10/12/2015) <br />