|
., r WATER / SEWER UTILITY APPLICATION
<br /> r ..
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT, WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857 I (E) everetteps@everettwa.gov I www.everettwa.gov/permits
<br /> l °PROJECT SITE INFORMATION
<br /> <���`�':, � �,�.,., ,,,��r ,�., ?'.x.�°�:��:��^ 3�.�t� °,3�..��,.s.} �..#;2�5?.r.. ...- .�.. .=�+�;r.>..`:Nx ,Us•,,-.,�.. .`?� j. .�s..t�ria�:� ? �, ...�,,...,,� .=x��'
<br /> PROJECT ADDRESS: yJ p 11 C Ceir W'�c9 dt 1 (�-/1�{ :\L $- tLJ f:L- 4_ `�3
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDIN AREA SF 0 LOT#
<br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ODULEX ❑MULTI-FAMILY-#OF UNITS: COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? o 0 YES, FROM TO
<br /> N U ,,kit APPLICA 1:01 1`NFO,RMATION `l i*144;4 - P 1
<br /> ...R.e �" aa „ �r� .. � . _.K.$...._ ,.. � ,..i'r.4.Va Kn: 5 .ti"i.x ,..+3g: wC%3-�.s_...3.Y„ 4,n..R �... :h rf4€w f ��s,.'.
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> ❑ SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION
<br /> IDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY
<br /> O NEW SIDE SEWER INSTALLATION SERVICE/METER USE:
<br /> ❑ 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 /> ❑ 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 /> 00 ATION •
<br /> �.... ....'.. ._ CONTACT INF ...,. . .�.,. . . 4... ...
<br /> OWNER NAME: VII e eXA A.a TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET 5c, 17 ( (or ow A W(¢06-",
<br /> CITY ' .ke 4 STATE 11-/L( Zips( 0
<br /> OWNER PHONE: .3Q rt7 oZ 4l OWNER EMAIL
<br /> ..,. .. v,.�,.. �._,., .r.� .,, ._.,r., .;M.. ..,_..-_�. _ ww _-,.. .u, .
<br /> CONTRACTOR NAME: tic)l M SrSL 1 (b 4% (It:
<br /> ,
<br /> CONTRACTOR ADDRESS: STREET PIZ• P,))c. .5-4, 5
<br /> \„4 CITY STATE Oa, ZIP q 7.., a4:,
<br /> CONTRACTOR PHONE: I-a$ „5 9(3/ CONTRACTOR EMAIL:itc,f yv?te A.. .Q/u b e�ve "2t^ ' COU
<br /> CONTRACTOR LIC.#REQUIRED://� 3 < CITY OF EVERETT BUSINESS LIC.#(R1tQUIRE �. 0,11091/3
<br /> CONTRA ( ) pfY��>f14 bb�J Wl Q
<br /> �.��....,.:.,...��;.�.,..u�.�.,.„_.w., .,...��.a .., rz<,�, �.,., .,m..4,...�,.., .� ,, ..K_,.. ..=:L�..h,�.,�. �r,,:..w.n. . m �.:, ..., R�,...,...,�y. -.....w......a.,N ....%.�K,.,�,.,.vv..�..,__x...,.. ....�. ...—R
<br /> PRIMARY CONTACT: 0 OWNER ,2'CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: [.�S a 3 r aa1:4,
<br /> e romI j Sl-{ / �
<br /> rey 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 h_
<br /> time. The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have t�� /� �/�
<br /> the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and ',/ I01
<br /> nonpayment of charges or for any other reasonable cause.I am the owner,or I am authorized by the owner of this / V
<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. U + ' n f^ 61 I
<br /> \-----1-7-4. , .,,:,4
<br /> Owner/Authorized Agent gnature ate (Revised 10/12/2015)
<br />
|