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.. WATEI� / SEViIIER U`T1LIT`Y ,APP'LIC�41'ION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT,WA 98201
<br /> (P}425-257-8810 � FAX 425-257-8857 � (E) everetteps@evereitwa.gov � www.everettwa.gov/permits
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<br /> �s- � rry �`� � � �� �� �� ��P 0:)�CT�SITE�INFORMATION` �� °';����� ���`fi%����
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<br /> PROJECT ADDRESS: (,� (,/
<br /> IF APPLICABLE: ❑OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT#
<br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY�#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE2 ❑NO ❑YES, FFtOM TO
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<br /> °� Ea �� r ' UTILITY APPLICATION kINFORMATION �`
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<br /> � SEWER(check all that apply) 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 /> ❑SIDE SEWER CAP-OFF ❑MULTI-FAMiLY-#OF UNITS:
<br /> ❑ SIDE SEWER RECONNECTION ❑COMMERCIAL
<br /> MULTIPLE DOMESTIG WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE:(circle desired size) .
<br /> ❑ 1 AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR ❑ DOM'EST[C: 3/4", 1", 2", OTHER:
<br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ IRRIGATION: 3/4", 1", 2", OTHER:
<br /> ❑�I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑ FIRE: 7", 2", 4", 6", 8", OTHER:
<br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER ❑ DOMESTIC/FIRE COMBO: 9", 2", OTHER:
<br /> SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF TH/S FORM,
<br /> "��°� �'� � � CONTACT INFORMATION y ,t. .,,.�<
<br /> OWNER NAME• TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: sTR�r
<br /> CITY STATE ZIP
<br /> OWNER PHONE• OWNER EMAIL•
<br /> CONTRACTOR NAME:��Zc9��4M �yR.ryN�»V
<br /> CONTRACTOR ADDRESS: s�xeer 14�.�j � I ! -� � I
<br /> CITY /` ��` /� STATE �G✓4' ZIP O����
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<br /> CONTRACTOR PHONE: CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): $G ZZ CITY OF EVERETT BUSINESS LIC.#(REQUIRED): C�3 77 Z L
<br /> PRIMARY CONTACT: ❑OWNE M �CONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: � ZS — 3 7/6 p� 2 �
<br /> � d�I � CONTACT EMAIL:
<br /> AGREEMENT.�The undersigned applicanf agrees to comply with all provisions of the EveretE Municipal Code Title City of Everetf Offtcial Use Only
<br /> 14 Water and Sewer or such other rules and regulations now existing or which may 6e established from fime to FEE �
<br /> time. The applicanf further agrees, as a condition precedent to receiving service fhat 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 ofherreasonable cause.l am fhe owner,or I am aufhorized by the owner of fhis
<br /> property to perform fhe work for which application is made,and I comply with the Sfate Contractors Law 18.27 PERMIT#
<br /> RCW and 2�OA,V,�.AG.�-�-- � �✓' // � � �������
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<br /> OwnerlAutho ' d Agent Signature ate (Revised 10/12/2095) ����
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