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. W,ATER / SEVi/IER. 11T'ILITY i4PPLICAI'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@everettwa.gov � www.everettwa.go�/permits
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<br /> PROJECT ADDRESS: C.(�J
<br /> IF APPLICABLE: ❑OUTSIDE CITY LIMI S ❑ 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 /> � SEWER(check all that apply) WATER(check all fhat apply)
<br /> SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION
<br /> ❑SIDE SEWER ALTERATION ❑COMPLETE SERVICE ❑METER ONLY
<br /> ❑ NEW SIDE SEWER(NSTALLATION 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 DOMESTIC WATER SERVIGES REQUEST WATER SERVICE TYPE/SIZE: (circle desired size)
<br /> ❑ I AM DECLINING MUL7IPLE DOMESTIC WATER SERVICES FOR ❑ DOMESTIC: 3/4", 1", 2", OTHER:
<br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ IRRIGATION: 3l4", 1", 2", OTHER:
<br /> ❑ i AM OPTING TO IIVSTALL 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. FILL OUT REVERSE S/DE OF TH/S FORM,
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<br /> _� � CONTACT INFORMATION
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<br /> x. $:
<br /> OWNER NAME: J�ZG; TENANT NAME(If Commerciai):
<br /> OWNER MAILING ADDRESS: STREET
<br /> CIIY STATE Z�P
<br /> OWNER PHONE: OWNER EMAIL:
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<br /> CONTRACTOR NAME: �C���
<br /> CONTRACTOR ADDRESS: ' sTReeT ��� �S i�,�w� �c � l�' C
<br /> C�-n. ��� ) STATE �e ZIP �X d
<br /> CONTRACTOR PHONE: CONTRAC70R EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): Zz R CITY OF EVERETT BUSINESS LIC.#(REQUIRED): D 77
<br /> PRIMARY CONTACT:��CI OWNER � ONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: Lf Z.� ` 3 ` OOZ
<br /> ��� 1 �j 1 CONTACT EMAIL:
<br /> AGREEMENT.•The undersigned applicanf ag�ees to comply wifh all provisions of the Evereit Municipal Code Title City of Everett Offcial Use Only
<br /> 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to FE E
<br /> time. The applicant further agrees, as a condition precedenf.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 for repairs,construction,and r
<br /> nonpayment of charges or for any other reasonable cause.1 am the owner,or l am authorized by fhe owner of this _
<br /> properfy to he work for which application is made,and I comply with the State Contracfors Law 98.27 PERMI,,,TTT��/^^^��������. ) /�
<br /> RC and 296.200A WA � �� � �(f,,l��� �/G,//�
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<br /> O orized Agent Signature Date (Revised 90/92/2015)
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