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ATE:- / SEWER UTILITY APPLICATION
<br /> -.- CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT, WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits
<br /> PROJECT SITE INFORMATION
<br /> PROJECT ADDRESS: SO/ I.nce,-/ art 4v
<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 El 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 /> Lit 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 /> 0 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: & re11 Lo.Trvh,J7 [r bl/e5e; TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET
<br /> CIN STATE ZIP
<br /> OWNER PHONE: // OWNER EMAIL:
<br /> CONTRACTOR NAME: �,Zo.�_.1cG,,,o lo Jc i e�..... ..... .:.,_,,,..,.,< ., .._. . s _ .<. _.._;.�...<-. ..._: ..,,.r._._... <. ... ..._,.,....,.:._.,._ ..,,..-.�.. ._,.,e._.._._.,..
<br /> CONTRACTOR ADDRESS: STREET ),g). S / 4 m ,5`/ (J
<br /> CIN c v 4G-c STATE LA ZIP °/g/Ye
<br /> CONTRACTOR PHONE: -,,,S 5 2.7L? CONTRACTOR EMAIL: C Ace/io+7C e p/'it,vy teC /.C6 r, �1
<br /> CONTRACTOR LIC.#(REQUIRED): /9AfCO/i, g ..k Z 5
<br /> CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 2 41
<br /> ::_,__.,...... :,. :. v.. _:,,.....»s,..1,..n
<br /> PRIMARY CONTACT: ❑OWNER -4 CONTRACTOR 0 OTHER(Please Specify)
<br /> CONACT NAME: CONTACT PHONE: 2_,c3 --5 (9g — 7'f
<br /> („41/ .40 0l'-lWGj Cl C CONTACT EMAIL: 6 r�
<br /> Grp7 f/�
<br /> e"/',cn/„le •G ur,
<br /> �/ u✓
<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
<br /> time.The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have FEE . ;'
<br /> the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and �`�
<br /> nonpay}nent of charges or for any other reasonable cause.1 am the owner,or!am authorized by the owner of this
<br /> property to perform the work for which application is made,and t comply with the State Contractors Law 18.27 PERMIT#
<br /> RCW and 200A LVAC /
<br /> = / 24 it/K u i ,o2/ teri, , ...
<br /> Owner/Autho - ed Agent Signature Date (Revised 10112/2015)
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