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/ SEWER UTILITY ii\PPLICATION
<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[ www.everettwa.gov/permits
<br /> PIIkOJECT SI1t INFORMATION
<br /> PROJECT ADDRESS: (4400 E1dP,(bl re.e.d� (�D�� E*i' f4 WA q$003iF APPLICABLE: 0 OUTSIDE CITY_ LIMITS 0 BUILDING AREA SF ❑//LOT#
<br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: 'CiCOMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? 0 NO ❑YES, FROM TO
<br /> UTILITY APPLICATION INFORMATION.
<br /> 1 SEWER(check all that apply) WATER(check all that apply)
<br /> Lel 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 /> ❑ 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- . .. ....
<br /> OWNER NAME:
<br /> TENANT NAME(If Commercial):C\A00 1o. C.�Ut,4\C\Ila.:•)\0.
<br /> OWNER MAILING ADDRESS: STREET
<br /> CITY STATE ZIP
<br /> OWNER PHONE: OWNER EMAIL: »
<br /> CONTRACTOR NAME: AP.,cj 7.-\(10k-el 1
<br /> CONTRACTOR ADDRESS: STREET 175 A . RCrj � 'S- *\c 'O1
<br /> CITY �Q/�( �
<br /> Poi:c' STATE Ocks\„,.()ror zip ICJO-�`/
<br /> �[.
<br /> CONTRACTOR PHONE: 2' RpgC&; -Jc(17 CONTRACTOR EMAIL: 1A3fQ a.('ti,� -3_,z\ r� co,
<br /> CONTRACTOR LIC.#(REQUIRED) N \ �Q7CITY OF EVERETT BUSINESS LiC.#(REQUIRED):
<br /> � =� _y_..�....-,_..�,�a.��.,.� ...�....,�n,...._..,..�.�....,. M,4..,,..,.-,..��......x,�.,,.�.,.»,�..-..,�,.,n..,,<,....,�...,.,�._,� ...,.»�..�.,....,.
<br /> PRIMARY CONTACT: ❑OWNER CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: ' (o\ crit
<br /> 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 rides 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
<br /> nonpayment of charges or for any other reasonable cause.I am 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 U PERMITVOt` f O��
<br /> RCW and 296. WAC. 1ig �l
<br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015)
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