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.. WATER. 1 SEVUER 11`TIL.1°TY APPLIC�4TION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 320Q CEDAR STREET, EVERETT, WA 98201
<br /> (P)425-257-8810 � FAX 425-257-8857 � (E) everetteps@euerettwa.gov � www.everettwa.gou/permits
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<br /> PROJECT ADDRESS: � 2j�r.�-1 ��."� �L S(� ��- �� g ��
<br /> IF APPLICABLE: ❑OUTSIDE CITY LIMfTS ❑ BUILDING AREA SF ❑ LOT#
<br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY�OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? ❑NO ❑YES, FROM TO
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<br /> ��°�` ���,' ' � UTILITY APPLICATION�INFORMATION ����"F`�'� �t` �s��z
<br /> ,pg, 5
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<br /> � SEWER(check all that appiy) WATER(check all that apply)
<br /> �SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION
<br /> ❑SIDE SEWER ALTERATION ❑COMPLETE SERVICE ❑METER ONLY
<br /> ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE:
<br /> ❑ INSTALL BACKWATER VALVE(outside the building) ❑SFR
<br /> CI SIDE SEWER CAP-OFF ❑ MULTI-FAMILY-#OF UNITS:
<br /> ❑SIDE SEWER RECONNECTION ❑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. ❑ IRRIGATION: 3/4", 1", 2", OTHER:
<br /> ❑�1 AM OPTIIVG TO INSTALL MULTIPLE DOMESTIC WATER ❑ FIRE: 1", 2", 4", 6", 8", OTHER:
<br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER ❑ DOMESTIC/FIRE COMBO: 1", 2", OTHER:
<br /> SINGLE OWNERSHIP. F/LL OUT REVERSE SIDE OF THIS FORNI.
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<br /> _� �ONTACT INFORMATION
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<br /> OWNER NAME: Nd� L n1 A�-A� TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: sTRe�'r �o� SoZ '�° P'' �
<br /> cirr t.�V Ci['�C�1''f- STATE � �P ��0�
<br /> OWNER PHONE: �O�" �S�f' I�{� OWNER EMAIL: SF����-�AN ��t'`'CB'�'N
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<br /> CONTRACTOR NAME: ��'� w'���
<br /> CONTRACTOR ADDRESS: sTREer �{f o��{ S'� ��'tf
<br /> CIIY �n'T'1(�.- STATE �/� ZIP 4 ��
<br /> CONTRACTOR PHONE: c�I�4`�3�J� ���� GONTRACTOR EMAIL: �--.---�
<br /> CONTRACTOR LIC.#(REQUIRED)' �j�S�PCS� !7 �'-�- CITY OF EVERETT BUSINESS LIC.#(REQUIRED): �03��f�S
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<br /> PRIMARY CONTACT: ❑OWNER .�ONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: ��(p^ �°j�.—Q7
<br /> ��� �A.nl.� CONTACT EMAIL:
<br /> AGREEMENT.�The undersigned appiicant agrees to comply with aU provisions of fhe Everetf Municipal Code Tifle City of Everett O�cial Use Only
<br /> 94 Wafer and Sewer or such other rules and regulations now existing or which may be established from time to FEE
<br /> fime.The applicanf 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 forrepairs,construction,and O
<br /> nonpayment of arges or for any other reasonaBle cause.1 am the owner,or I am authorized by the owner of fhis
<br /> pr erfy o p rf m the worfc for which appiication is made,and I comply wifh the State Contractors Law 98.27 PERMIT#
<br /> R an 29 .2 A WAC. n /��- �.�J � 1 r�,�G�' � {�'� ( /''�
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<br /> OwnedAuth rized Agent Signature Date (Revised 90/92/2095)
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