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<br /> WATE i! SEWE!! UTILITY A PPU C TI
<br /> _- CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT, WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857 (E)everetteps@everettwa.gov I www.everettwa.gov/permits
<br /> PROJECT SITE INFORMATION
<br /> PROJECT ADDRESS: /7/)- ;n u ,otic
<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 0 YES, FROM TO
<br /> UTILITY APPLICATION INFORMATION
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> pi 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 /> 0 SIDE SEWER RECONNECTION 0 COMMERCIAL
<br /> MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE:(circle desired size)
<br /> ❑ 1 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 /> CONTACT INFORMATION
<br /> OWNER NAME: fca rti SC,1/i(, TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET /7/Z iZA;A e-- Ave
<br /> CITY t"utrC I1 STATE L'tit ZIP G O(
<br /> OWNER PHONE: 4,2-5-3621-- .6)2 OWNER EMAIL:
<br /> ,
<br /> CONTRACTOR NAME: ./' G.0 i_..7-C4,-.11,..04);C
<br /> �,�„����,e,�.. ... . ....,.,,« ., .z,.:.>..� . :..<.._,.z .�.,.<_ .,., ..�.._ .. .. .. .._.:............ ,..-,. .
<br /> .,_ . .
<br /> CONTRACTOR ADDRESS: STREET 2,g 2 5 5 /5 fir' 5 IC
<br /> CITY Sea m C STATE t.„. ZIP ( P g
<br /> CONTRACTOR PHONE: .20(-2c9,5)7 o CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): p/2j[ o7/ 'C5/t7- CITY OF EVERETT BUSINESS LIC.#(REQUIRED): £32 f l
<br /> PRIMARY CONTACT: ❑OWNER I CONTRACTOR 0 OTHER(Please Specify) (> `
<br /> :
<br /> CONTACT NAME: CONTACT PHONE: 2 3 /s o 0 -n49 -(� 2 /
<br /> p A ort f/
<br /> en-, V C CONTACT EMAIL: / v � tc, ><�' h,Gar,
<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 �O( r
<br /> the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and ��/�
<br /> CC-) i
<br /> nonpayment of charges or for any other reasonable cause.lam the owner,or 1 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 PERMIi#
<br /> RCW and 6.200A W
<br /> f/2//� _-_
<br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015)
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