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'IP" ATE / SEWER UTILITY APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT, WA 98201
<br /> (P)425-257-8810 J FAX 425-257-8857 J (E) everetteps@everettwa.gov J www.everettwa.gov/permits
<br /> PROJECT SITE INFORMATION
<br /> PROJECT ADDRESS: a C-e&IQ 2S--,
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: BSFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? IPNO 0 YES, FROM TO
<br /> UTILITY APPLICATION INFORMATION
<br /> �� SEWER(check all that apply) WATER(check all that apply)
<br /> IoTSIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION
<br /> ❑SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY
<br /> ❑ NEW SIDE SEWER INSTALLATION SERVICE 1 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 /> _
<br /> CONTACT,INFORMATION
<br /> OWNER NAME: )(jailS'er/ C (,I TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESJ: STREET ( Q 11 C-toc r
<br /> CITY J(J1 i...,/,4 6 Nr STATE /1d ZIP g2V/
<br /> OWNER PHONE: OWNER EMAIL: 1JC/5-fault y 9!{l1Cv.021-4,
<br /> CONTRACTOR NAME: 4 in-6- C4 eap -GK`,
<br /> CONTRACTOR ADDRESS: STREET ?VI / Aid" AVE' ,? P - 9
<br /> cm' 6-eV/ !' STATE L / ZIP ed/O)
<br /> CONTRACTOR PHONE: 2O� 6d// /f 3 2 CONTRACTOR EMAIL: 6jlClq dee pad mow? v
<br /> CONTRACTOR LIC.#(REQUIRED): .74?CG. g-86137 CITY OF EVERETT BUSINESS UC.#(REQUIRED):*J� 0 �05
<br /> � �..,<,� ..,_.,:::,�_:.:._...1,.�_._�,�_.,�...,<:....._,..,.F>_..,»..,_s:.F�f..__�..: ...,.,,...,_.v., _ ..,m...:��..:.:.-.<_.x,.._...,:........�...<.�.
<br /> PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR L�OTHER(Please Specify) S-eM' 1 c Cquotitz G-6/--2s1- ,S43
<br /> CONTACT NAME: /' / CONTACT PHONE: gC/ '75-9-- f C-a3
<br /> 14 C)co (�-e/q/ac("C`c f 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 D
<br /> the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and
<br /> nonpayment of charges or for any other reasonable cause.lam 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. 4'7—G/- / Ill 4-U „ O _ ( y i 7
<br /> Owner/Authorized Agent Signature Date (Revised 10/1212015)
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