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TER / SEWER UTILITY LPP UCATION
<br /> „./AA•ii,....._
<br /> ilLCITY OF EVERETT PERMIT SERVICES
<br /> r 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: 5-6 2-/ ,,2L ,//r'2 74
<br /> IF APPLICABLE: ❑, FR OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: L-)dFETACHED ❑SFR ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL El INDUSTRIAL
<br /> CHANGE OF USE? El YES, FROM TO
<br /> UTILITY APPLICATIONINFORMATION
<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 /> 0 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 /> ❑ 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 /> P-44.. .. ��
<br /> OWNEERR NAME: ,Gre--a TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET .T' 2/ G.- P/ -//r-, ,e -"—
<br /> CITY
<br /> CITY I --nE-r---7-- STATE WA" ZIP
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME:
<br /> »v.,»,N.,.�,.,�.,�.......N.�. ----vii .w...,,,M�-e- -C-G,7'/!/Z'S.,...,.....�M�.�....,,,.
<br /> ES
<br /> CONTRACTOR ADDRESS: STREET �%5— /S -711e1-711e1- ' yl T'— j
<br /> CITY S/V a,41d /6' STATE Y V ZIP 9,290
<br /> CONTRACTOR PHONE: CONTRACTOR EMAIL:
<br /> CONTRACTOR LICA#{REQUIRED): 5&---14/E7117*-/ CITY OF EVERETT BUSINESS LIC.#(REQUIRED): _— -„-
<br /> PRIMARY CONTACT: WNER 0 CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: ¶26 /2 3 ce1-94-
<br /> 7 -2 )(2_A-,1) 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 h;�
<br /> time.The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have 4W L�
<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 I am authorized by the owner of this
<br /> property to perform th- • 'for which application is made,and I comply with the State Contractors Law 18.27 PERMIT#
<br /> RCINand 296. '%' W' r� 1 1 i, u 1 1th 02'-1 \
<br /> Owner/Authorized Agent ure Date // �(} (Revised 10/12/2015)
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