|
W`ER / SEWER UTILITY PLICATION
<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.gov/permits
<br /> >. ` �'�# '� � �`�'�� ����� `�PROJEC�T�SITE�INFORMATION� � ����°° �� ��� �� ����� �`�� y
<br /> � ��
<br /> . r�,�<ax � ,�.. a.,,."���,.�.rt�.. ��c"'�.� :;x�s���a,�..+.�w �r�r.,s �,r;�rt�a.�Zx�,,.,.��:��. »F+� s�.raa��...�,�_ Ma�'.�s _��, ..�r,,.�,.,� .��.:_.. �.�._� r;
<br /> PROJECT ADDRESS: � ��� ��/� � �"J- S�Z�
<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 USE? ❑ NO ❑YES, FROM TO
<br /> , , e , �
<br /> �. �k:. ,. .:` ,_ ; ,. "..:_ UTILITY APPLICATION 1'NFORMATION rY �; . � .;: ..�`,� ._ ,_
<br /> SEWER(check all that apply) WATER(check all that appiy)
<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 /> T�SIDE SEWER CAP-OFF ❑ MULTI-FAMILY-#OF UNITS:
<br /> ❑ SIDE SEWER RECONNECTION ❑ COMMERCIAL
<br /> MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE: (circie 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. ❑ �RRIGATION: 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: 1", 2", OTHER:
<br /> SINGLE OWNERSHIP. FILL OUT REVERSE S/DE OF THIS FORM.
<br /> 3� CONTACT INF10RMATION ;
<br /> a_::.v „ _. ..rt _ ._... .,.. ..
<br /> .._ . . ,._ ._._ �_� _
<br /> OWNER NAME: ' V �P ha o�P�� TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET S � .�
<br /> CITY Q��� STATE rj✓� ZIP `�/ c.N.�
<br /> OWNER PHONE: ZS� 2ci 3 r" ,G OWNER EMAIL: Cr �.1 2 r�' f"��'"��� �1
<br /> CONTRACTOR NAME: L_
<br /> CONTRACTOR ADDRESS: sTrteer
<br /> CITY STATE ZIP
<br /> CONTRACTOR PHONE: CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED):
<br /> PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE:
<br /> CONTACT EMAIL:
<br /> AGREEMENT.•The undersigned applicant agrees fo comply with al!provisions of the Everett Municipal Code Title City of Everett Official Use Only
<br /> 94 Water and Sewer or such other rules and regulations now existing or which may be established from time to FEE ��
<br /> time. The applicant further agrees,as a condition precedent fo receiving service that the utilities division shall have � ^
<br /> the right at any fime,without notice,to shut off or turn on fhe water supply for repairs,construction,and F � �
<br /> nonpaymenf of charges or for any ther reasonable cause.!am fhe owner,or 1 am authorized by the owner of this �•J`
<br /> propeity to perform the work fo hich application is made,and I comply with the State Contracfors Law 98.27 PERMIT#
<br /> RCW and 296.200A WAC.
<br /> L �� f 6 U ��Q��,--'
<br /> Owner/Authorized Age ignature Dat (Revised 90/92/2015)
<br />
|