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WATER / SEWER UTILITY APPLICATION
<br /> 4reerr
<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
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<br /> E aC� : , PROJECT ttg NFORMATIONr n r �{ M M
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<br /> PROJECT ADDRESS: C ( -44* zg e5 egc c Sec
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ODULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? 0 NO 0 YES, FROM TO
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<br /> � ,,< �! UTILITY APPLICATION INFORMATION • ;i 1,11 Myt z6 � � � ��
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> ❑ SIDE SEWER REPAIR 'EW WATER SERVICE I • LATION Z
<br /> ❑SIDE SEWER ALTERATION COMPLETE SERVICE J METER ONLY
<br /> O NEW SIDE SEWER INSTALLATION - SE:
<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 /> C •
<br /> ONTACT INFORMATION •
<br /> OWNER NAME: ecth me- Ate fo.tr DY(/LcO,*1a/r TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: sTREE//Z O s1.4' AYT /1.,4eC- 14940V $'w i3-L /t7
<br /> CmY C t✓w r ^STATE P/19 ZIP 4.39Z-0
<br /> OWNER PHONE: I/IS-Z97—(�}` a
<br /> f g3 OWNER EMAIL: 6ha.he.I s'eehp.A.e. o,vl
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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 ❑CONTRACTOR ❑OTHER(Please Specify) S,,,Oerrnn
<br /> CONTACT NAME: CONTACT PHONE: e/Z 5-- n7_ c-/P3
<br /> 5411Aft e £.71Ch ar7 CONTACT EMAIL: Sl:�_e , 5.& Spgpa c hoa 1 is , Gc '3
<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 notice,to shut off or turn on the water supply for repairs,construction,and 4z- ttp
<br /> r /
<br /> nonpayment of charges or for any other reasonable cause.l am the owner,or I am authorized by the owner of this
<br /> property to perform the work for which application is made,and I comply with the State Contractors Law 18.27 PERMIT#
<br /> RCW and 298.200A WAC. / �Z.0 f N O ` O7
<br /> Owner/Authorized Agent Signature Date • (Revised 10/12/2015)
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