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WAR / SEWER UTILITY PLICATION
<br /> #1111111—A4, .
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT, WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857 I (E) everetteps@everettwa.gov I www.everettwa.gov/permits
<br /> :--1:V11;6-'-i-P' "` jl:'q ' X:Ar -d*l SI E INFORMA7'IO:N ' , i ' z," , $, ,r .. . 1
<br /> PROJECT ADDRESS: /69e6 S6 �0.415-xz-77-'/"lam// J y
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: 1 COMMERCIAL 0 INDUSTRIAL
<br /> CHANGE OF USE? 0 NO 0 YES, FROM TO
<br /> i a"f `„ UTILIT 7:FYP"CA1'IONcINr:°:M TION � t H
<br /> ,- �za� ��,..,.w°"k:.. �. .,z{s,�Ss7.,.'.,,...„.�yS��,�,�ke,s�.,�s,��ne.r,Clae�er.a�«s!�v;�Nzw.u�o-. n3x�,�..m re�ff tt'c�,ae�.�:�-�^c,ek..y..'�a.'c 4.,s3�*+ ��,...vv.."-.z� z�..."w�i...4.tial
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> ❑SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION
<br /> IN SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY
<br /> I_. , ,, - i - ,, - _ , _' •. 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 0 DOMESTIC: 3/4", 1", 2", OTHER:
<br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. 0 IRRIGATION: 3/4", 1", 2", OTHER:
<br /> ❑.I 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: 1", 2", OTHER:
<br /> SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM.
<br /> CONTACT INFORMATI ,. .
<br /> OWNER NAME: PLL-4..a C- 6-2� s,e c 7r/ 1SNANT NAME(If Commercial): ge/771/21) F‘cs V
<br /> OWNER MAILING ADDRESS: STREET /0 an .5",67. 6";&--7.26-'77- A 4[I t4g.,f .
<br /> CITY E v626-?T STATE WA ZIP
<br /> OWNER PHONE:1.04 6SL 139'Z' OWNER EMAIL:
<br /> CONTRACTOR NAME: 5e ? Z7/6' 1 G Y✓0/L�S
<br /> CONTRACTOR ADDRESS: 7© f STREET 'Z i t�-u- Ps-. 6-67 3(ack 'fafry?€?/Vel STATE Vv A
<br /> ZIP ` ,
<br /> CONTRACTOR PHONE: ZD 6 383 48 20 CONTRACTOR EMAIL: -7e-a E/�i 6),A2012>5 biAn. . ‘ eC0 w ',
<br /> CONTRACTOR LIC.#(REQUIRED): -56-14 7-7-Pi Z 1 k 8S CITY OF EVERETT BUSINESS LIC.#(REQUIR'D): (,
<br /> PRIMARY CONTACT: ,I CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: (( CONTACT PHONE: e$ G (3,613 d8 Z 6 ---2—
<br /> / )� W
<br /> "� ' z S� CONTACT EMAIL: s&--,477-/670,.p lc9o12kS��j I^a t\- CO tv�
<br /> AGREEMENT.The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title _—Y 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 on.-ion precedent to receiving service that the utilities division shall have .....-----_
<br /> the right at any time without notice,to s t o or turn on the water supply for repairs,construction,and 3C)
<br /> nonpaymen ; c ar•: • or an other r=.so ab' .0 -. .am the owner,or I am authorized by the owner of this
<br /> property perfor ife wor pp'a i• is r-•e,and I comply with the State Contractors Law 18.27 PERMIT#
<br /> 7.29. 0AWAC. , /; . 3r U \ OO2
<br /> Authorized •gent Signature Date (Revised 10/1212015)
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