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ATFL / SEWER `nu APPLUCATIO
<br /> -__ CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT, WA 98201
<br /> (P)425-257-8810 1 FAX 425-257-8857 1 (E)everetteps@everettwa.gov www.everettwa.gov/permits
<br /> PROJECT SITE INFORMATION
<br /> PROJECT ADDRESS: (002-4 ZO CJc✓ Ar_
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: ,SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? 14,NO 0 YES, FROM TO
<br /> UTILITY APPLICATION INFORMATION
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> vi SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION
<br /> ❑SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY
<br /> ❑ 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. ❑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 /> CONTACT INFORMATION
<br /> OWNER NAME: irhww I,.)VN. TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: sTREET 6,0Z--4 il-pSe, C4( _ / llC-
<br /> cITY G v!✓tri STATE �A ZIP { a Z.O 3
<br /> OWNER PHONE: �,( �e61 OWNER EMAIL:
<br /> ..- SatJ� .�_. .. „� Jw��..,�
<br /> ° ` n.,. __ _._...,.�....�_=a..,,_.�ti...,-. ..,.. ...v...__ ..� .. _.. .<u.,...,.,.-._..,_ ....,..-._...._,.,�.�.-.....,
<br /> CONTRACTOR NAME:
<br /> CONTRACTOR ADDRESS: STREET Z tt)1 St..) AL- S4-
<br /> CITY 5Ze.A.. STATE LA)Ar ZIP 9160
<br /> CONTRACTOR PHONE: ZOCp'Ct 3 Z- 111-1 CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): SO UT!A Li?Ol l [,(p CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 0 3 O U
<br /> PRIMARY CONTACT: ❑OWNER CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: : MA?A CONTACT PHONE: zac, - L{,5 g.. 44 SC-)
<br /> 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 may be established from time to FEE
<br /> time.The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have
<br /> the right at any time,without not', ,to shut off or turn on the water supply % repairs,construction,and
<br /> nonpayment of charges or for- 'other re.: a.e...use.I-• the o - or I am authorized by the owner of this
<br /> property to perform the wo •- which a y :tion is ad: and I co,ply ith the State Contractors Law 18.27 PERMIT#
<br /> RCW and 296.200A WA
<br /> ,L ��;/ ilii. , I I57c e U 1 01 -- 0 0
<br /> Owner/ uthorized Agent Sig %ture Date (Revised 10/1212015)
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