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WATER I SEWER UTILITY APPLICATION <br /> #.111 -1 . <br /> 4 d , : CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> (P)425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits <br /> ;, 3 Tqt ' PR°Vg6 :tiW tjfig ATiON` x . .r x ... ..... .. .. <br /> 1 o' M,FY+ 4PSf '. r _ Pa^' ::tE•:5:. +9». .�Eb <br /> PROJECT ADDRESS: ' ?�„ fl(.2_, a - <br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# <br /> BUILDING TYPE: ❑SFR DETACHED ❑SFR ATTACHED ❑DULEX.kr//ULTI-FAMILY-#OF UNITS: G/ ❑COMMERCIAL [INDUSTRIAL <br /> CHANGE OF USE? /1Z(N0 0 YES, FROM TO <br /> , �,'" :: UT11.ITll'APPLICfttiti }INFORMATION ` i 7 ;` '� " - I , Y.s <br /> y. ": '' 1..r t:%'k: �'+�Y1\4._.._"c e..+W2+iM"vhY.'�+3x6LM5E Yb�' He.}p 3iY..t6" e2Yi <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 0 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 0 DOMESTIC/FIRE COMBO: 1", 2", OTHER: <br /> SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. <br /> x <br /> .��.��.�..- '--- .,.... CONTACT INFORMATION <br /> OWNER NAME: >D f/ /foe TENANT NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET � ... ..-›... ()K1 7"z s <br /> CITY E- STATE i 7(Q- ZIP p Q4 <br /> OWNER PHONE:` 5/ ,cg OWNER EMAIL: <br /> CONTRACTOR NAME: r/#114--/-74— <br /> �t <br /> CONTRACTOR ADDRESS: _STREET IJ :O. VVV1 Q.R‘ •- ''nn <br /> CITY ::://'-/ `LLLSTATE ZIP4 )b(-) <br /> CONTRACTOR PHONE: Y.-- (06,,,, CONTRACTOR EMAIL: DDDD���✓✓�� �L. <br /> CONTRACTOR LIC.#(REQUIRED): ibikteLS p ,,,,, 2___CITY OF EVERETT BUSINESS LIC.#(REQUIRED):e 6D,R6,cly <br /> PRIMARY CONTACT: ID OWNER J 2ONTRACTOR 0 OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: ,,� a?�7 g g e0( <br /> CONTACT EMAIL: b' <br /> AGREEMENT:The and s ned 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 /> 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 ----- <br /> nonpayment of charges or for any other reasonable cause.I am the owner,or!am authorized by the owner of this <br /> property to perform the work for which application is made,and!comply with the State Contractors Law 18.27 PERMIT# <br /> RCW and 2g6.20 WAC. U \ \ 2 y O`er <br /> ,---------1 J� L <br /> Owner/Authorized Agent ignature / Date (Revised 10/12/2015) <br />