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WATER / SEWER UT LITY APPLICATIO N
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT, WA 98201
<br /> (P)425-257-8810 J FAX 425-257-8857 I (E)everetteps@everettwa.gov i www.everettwa.gov/permits
<br /> PROJECT SITE INFORMATION
<br /> PROJECT ADDRESS: aF ' i"Z / / 7L'A r iJ v 2 ' ^ (A_. 7 k U 1/4-1
<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: 4 ❑COMMERCIAL DINDUSTRIAL
<br /> CHANGE OF USE? pig NO 0 YES, FROM TO
<br /> UTILITY APPLICATION INFORMATION
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> .JD 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 /> 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 /> IFJ-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 INFORM....
<br /> OWNER NAME: TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: sirseT
<br /> CITY STATE ZIP
<br /> OWNER PHONE: OWNER EMAIL:
<br /> ,
<br /> CONTRACTORNAME:,., ... .�,.�_�. <.,�.. .,... a_Cw�.. __....�,�..,- _.�,..�....._e_. ..,., ...,,,:.�. �, .. ... ..u,.w,..�<LL .,,...,�,�.. �.,�,n...�...
<br /> CONTRACTOR ADDRESS: STREET I `t' S 54 t CJ t
<br /> crrY C _ L r STATE L . C ZIP 1 �y U c.
<br /> (
<br /> CONTRACTOR PHONE: Z p(,, 2 ` 7( 2 U CONTRACTOR EMAIL: 111
<br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED): © 1 5
<br /> PRIMARY CONTACT: ❑OWNER ,-CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: z U G 'z S L Z � 2 U
<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 /> time.The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have (7
<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.lam the owner,or I am authorized by the owner of this r
<br /> property to perform the work for which application is made,and 1 comply with the State Contractors Law 18.27 PERMIT#
<br /> RCW and 296.200A WAC.
<br /> I U 19) n'kctot4
<br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015)
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