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0A11P. WATER / SEWER UTILITY APPLICATION
<br /> silicWi 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 /> t .. OJECT SI f4I01F0 MATIO 1 yip ,
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<br /> PROJECT ADDRESS: DP-) l g (c'r
<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? )(NO 0 YES, FROM TO
<br /> U ILITY APPLICATION INFORMATION r
<br /> �.,,. SEWER(check all that apply) WATER(check all that apply)
<br /> ti\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 /> Q 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 /> C NTA ORMATi.h
<br /> OWNER NAME: {� p„A/v TENANfi"MA i (If ommercial):
<br /> Y� �► f
<br /> ���j a
<br /> OWNER MAILING ADDRESS: STREET tjAitkPL \)D nsev--
<br /> CITY STATE ZIP
<br /> OWNER PHONE: OWNER EMAIL:
<br /> , t, , .. w.,.. ,.., . .,.vW. N.Mu .. .._.-_— .... _. —. _ ..,...,., ,-..,....uv: .r. . W.,, r _. _ „ ..,w.r w.CONTRACTOR
<br /> -CONTRACTOR NAME: w' /�
<br /> CONTRACTOR ADDRESS: STREET iiun., PhiV AW Ia/ lite).
<br /> CITY N`„ STATE WA • ZIP o,
<br /> 0106
<br /> CONTRACTOR PHONE:” ` l:01.2A CO TRACTOR EMAIL:�p1VVlY►h1l IC 2/'l101n •`;( t4 t
<br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BU51N LIC.#(REQUIRED): O , w
<br /> PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: • CONTACT PHONE: (L4 .)49)5-b1'7 ,
<br /> atitf -11 N/ , 1,1 Ir "14,---- CONTACT EMAIL: /� l VVi�VI.�i [ Ic 1 �/IG�,I .`I�I
<br /> AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipall/ de Title City of Ever Official Use Only
<br /> -_ .
<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, . a coni , precedent to receiving service that the utilities division shall have
<br /> the right at any - e,w' • t notic.,to shut off o turn on the water supply for repairs,construction,and
<br /> AW61— -.°.
<br /> r
<br /> nonpayment.f ch- •-s or or an other reasona.le cause.I am the owner,or!am authorized by the owner of this
<br /> property top- .r he wo` . hich applicatio is made,and I comply with the State Contractors Law 18.27 PERMIT#
<br /> Owyvand29:200 ,_ ' �� ��� ��i - o'D-1
<br /> ner/Authoriz :� gent Sig ature Dat (Revised 10/12/2015)
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