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WATER / SEWER UTILITY APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT, WA 98201
<br /> (P)425-257-8810 FAX 425-257-8857 I (E)everetteps@everettwa.gov I www.everettwa.gov/permits
<br /> r . ,.. MAICW rO PROJECT SITE IN ORMATION, h„,faeC_,...,.._.
<br /> PROJECT ADDRESS: 79ZQ .13,420/4-0.4Q / Ps-aLa 1 SGS 06;?()Q4cG I
<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? 0 NO ❑YES, FROM TO
<br /> 111•671,; '' � �,•„' �+5{e k!f g� i��c4� �.5 S�'�X �;- v. u.� i �d'
<br /> UTILITY APPLICATIO:Na�I 0,091:TION sYi;� l�:�;, �' ”. �°' t$IMi 't.a
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> ❑ SIDE SEWER REPAIR • -••• _ - . -. ►STALLATION ea-3
<br /> ❑SIDE SEWER ALTERATION E. COMPLETE SERVICE t. 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 /> 0 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 ❑DOMESTIC: 3/4", 1", 2", OTHER:
<br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. IRRIGATION: 3/4", 1" 2", OTHER:
<br /> 0 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: AL.PA/ C Ate tow-- Dec(6.cohig T TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET/Z 0 5'141 eVERA_7T Alga- 1444¢e/ .41 I J-1 / n
<br /> crrY e f.�,tery- STATE 49 ZIP 4(59Z-0>1.
<br /> OWNER PHONE: 112S-297--e?t'f g3 OWNER EMAIL: 5A4.h e.Id S2ct f►gc 400-74,..c, core
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<br /> CONTRACTOR NAME:
<br /> CONTRACTOR ADDRESS: STREET
<br /> CITY STATE ZIP
<br /> CONTRACTOR PHONE: CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED):
<br /> PRIMARY CONTACT OWNER 0 CONTRACTOR 0 OTHER(Please Specify) S1-0,teem1 i<Fn .e.,*
<br /> CONTACT NAME: CONTACT PHONE: ciz c 29'7 c P3
<br /> 5AArt e ECONTACT EMAIL: St,e, , b.& SpApez c korai e s . Coen
<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
<br /> time. The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have FEE }}
<br /> the right at anytime,without notice,to shut off or turn on the water supply for repairs,construction,and l 25 1 I n O-'
<br /> nonpayment of charges or for any other reasonable cause.l am the owner,or lam authorized by the owner of this 1 l.1/c
<br /> property to perforin the work for which application is made,and I comply with the State Contractors Law 18.27 PERMIT#
<br /> RCW and 296.200A WAC. I
<br /> 1f—i �-49/b U � 9 QLf - t
<br /> Owner/Authorized Agent Signature Date • (Revised 10/12/2015)
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