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WATER / SEWER UTILITY APPLICATION
<br /> 1• CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT, WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857 1 (E) everetteps@everettwa.gav www.everettwa.gov/permits
<br /> PROD Ct SITE INFORMATION x u
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<br /> PROJECT ADDRESS: "6.3^ 5--(:,3c) i)-3 euQ(la 4/1
<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 /> 1•4 UTILITY APPLICATION INFORMATION 1 . t._ kfa,,.N, ,
<br /> apply)
<br /> SEWER(check all that apply) WATER(check all that pp Y)
<br /> DE 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. 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
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<br /> OWNER NAME: C7 v7 ()Do v,i,,/ TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET S I
<br /> CITY STATE ZIP
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME: 17 extr, UZ 026+4—
<br /> CONTRACTOR
<br /> CONTRACTOR ADDRESS: STREET /Ot',3//S-- 7E k•w ii, ii • [3.71_, - lQ Sq��
<br /> CITY ri�(1"'<(lC STATE CieZIP 7P, (,
<br /> CONTRACTOR PHONE: CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): V affFSC,12Z(3 CITY OF EVERETT BUSINESS LIC.#(REQUIRED): o3 77 z.tf
<br /> PRIMARY CONTACT: ❑OWNER CONTRACTOR 0 OTHER(Please Specify) , ._
<br /> CONTACT NAME: CONTACT PHONE: L-1'Z S' - 3-7/6 - C'c ?
<br /> Kr1 S 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 J} ,c 91C�
<br /> the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and ` Oa`J) lJ.
<br /> nonpayment of charges or for any other reasonable cause.I 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 296,200A WAC.,,,,,' u \ L4 9 \ ,,.._._...
<br /> OwperfAuthorized Agent Signature ate 6 (Revised 10/12/2015) /
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