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<br /> TER / SEWER UTILIT 'PLICATION
<br /> f ' 01CITY OF EVERETT PERMIT SERVICES
<br /> di
<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 /> PROJECT SITE INFORMATION
<br /> PROJECT ADDRESS: 7/S 94/ S7I- SE
<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: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? 0 NO 0 YES, FROM TO
<br /> UTILITY APPLICATION INFORMATION
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> IDE 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 /> 0 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 INFORMATION
<br /> OWNER NAME: Ow WJE 1--)c 5 1c/,1,, TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET 0 vs')E
<br /> CITY STATE ZIP
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME: izo tr_,.i2t.,04.e
<br /> CONTRACTOR ADDRESS: STREET /0,,S S ,.. ��riG ze,i a/ 3(.'
<br /> CITY ,,,a[. r fie. STATE kit, ZIP 91136.
<br /> CONTRACTOR PHONE: CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): 8010 E SC ("Z Z IS 3L CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 0377`i1
<br /> ,.,<.�_�=.t.,..w_��.,m..:�M_.�,,.,«u�:.aar.�..�. __ _4__ v....L`..�_.:...M T,:,._ ____: _t._ r_v_,__,a,.:,.,......,....,_. ...,,_� _ m.._���,.____„_._-
<br /> PRIMARY
<br /> <_ _.n..y._PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 0 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 maybe established from time to FEE
<br /> '
<br /> time.The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have
<br /> the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and O0
<br /> nonpayment of charges or for any other reasonable cause.lam the owner,or I am authorized by the owner of this
<br /> property to perform the work for which appy is made,and I comply with the State Contractors Law 18.27 PERMIT# �n
<br /> RCW and 296. A WAC. U no I - O 1D lY
<br /> Ow er/Authorized Agent Signature Date (Revised 10/12/2015)
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