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i .._ •TER / SEWER UTILITYVPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT,WA 98201
<br /> (P)425-257-8810 ( FAX 425-257-8857 (E) everetteps@everettwa.gov{ www.everettwa.gov/permits
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<br /> PROJECT ADDRESS: q 2 teas M ; evE kTT, ( UNIT g
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: C1SFR-DETACHED IXSFR-ATTACHED ODULEX MULTI-FAMILY-#OF UNITS: Z. OCOMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? 0 NO 0 YES, FROM TO
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<br /> .,...., SEWER(check all that apply) WATER(check all that apply)
<br /> ❑SIDE SEWER REPAIR lX1 NEW WATER SERVICE INSTALLATION
<br /> ❑SIDE SEWER ALTERATION COMPLE i t SERVICE D METER ONLY
<br /> O NEW SIDE SEWER INSTALLATION SERVICE/METER USE:
<br /> 0 INSTALL BACKWATER VALVE(outside the building) 0 SFR
<br /> ❑SIDE SEWER CAP-OFF ®MULTI-FAMILY-#OF UNITS: •-
<br /> ❑SIDE SEWER RECONNECTION 0 COMMERCIAL
<br /> MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE: (circle desired sire)
<br /> ❑I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR 16 DOMESTIC: c 1", 2'e., OTHER:
<br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. 0 IRRIGATION: 3/4", 1" 2", OTHER:
<br /> 0(1 AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER 0 FIRE: 1", 2", 4", 6" 8°, OTHER:
<br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER 0 DOMESTIC/FIRE COMBO: t", 2", OTHER:
<br /> SINGLE OWNERSHIP.FILL OUT REVERSE SIDE OF THIS FORM.
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<br /> OWNER NAME: 45NIS11StA-I kiK /S t WYt 3 SA' FINTENANT NAME r If Commercial):
<br /> OWNER MAILING ADDRESS: STREET ti 64-0 1 UAW t3 kD CT,
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<br /> CITY -MO •T STATE CA ZIP ”!-1• 1
<br /> OWNER PHONE: 4310-~ '95'2— OS ' OWNER EMAIL: A-CA&I A 14 ar &MALL. . Um,
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<br /> CONTRACTOR NAME:
<br /> ,CONTRACTOR ADDRESS: STREET
<br /> CITY STATE ZIP
<br /> CONTRACTOR PHONE: CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#REQUIRED): CITY OF EVERETT BUSINESS LIC.#{REQUIRED):
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<br /> PRIMARY CONTACT: OWNER 0 CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME:Olaf CAN AN CONTACT PHONE: 90-" ,SS2.-- O 41
<br /> CONTACT EMAIL: AK.ttt NA7 g) 6 A L • un
<br /> AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title 14 Water and Sewer or such other rules and regulations now
<br /> existing or which may be established from time to time.The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have the right at any
<br /> time,without notice,to shut off or turn on the water supply for repairs,construction,and nonpayment of charges or for any other reasonable cause.I am the owner,or I am
<br /> authorized by the owner of this property to perform the work for which application is made,and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC.
<br /> City of Everett Official Use Only
<br /> PERMIT#
<br /> Owner/Authorized Agent Signature Date (Revised 9/23/2016)
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