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<br /> WATER I SEWER UTIUUT APPLICATION
<br /> CITY'OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET,EVERETT WA 98201
<br /> (P)425.257-8810 j FAX 425-257-8857 I (E)everetteps evereftwa gov I wwweverettwa. vlpetrni
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<br /> ;�. .. � '�„. ���, �, � � tilf*.x;'u �� 'igg _
<br /> PROJECT ADDRESS: ', Vit. tel TGteye V Pea K., Vie.
<br /> IF APPLICABLE: Ci OUTSIDE CITY LIMITS Cl BUILDING AREA SF a LOT
<br /> BUILDING TYPE: FR-DETACHED C3SFR-ATTACHE#) CIDUi EX QMLILTI-FAMILY-OF UNITS:__ T :QCOMMERCIAL J11NDi STRIAL
<br /> CHANGE OF USE? Cl•NO I YES, FROM d; TO .,C4/
<br /> SEWER(check all that apply) WATER(check all that applyl
<br /> Q SIDE SEWER REPAIR 1..ecie y,tr,c„ 0 NEW WATER SERVICE INSTALLATION
<br /> '©SIDE SEWER ALTERATIQN oA ti"
<br /> C1COMPIiETE SERVICE 0 METER ONLY
<br /> %NEW SIDE SEWER INSTALLATION ` V'
<br /> SERVICE,/MOt i USE:,
<br /> Cl INSTALL BACKWATER VALVE(outside the building) . Q;SFR
<br /> ' -Q SIDE.SEWER CAP-OFF Cl MULTI-FAMILY-#OF UNITSt
<br /> 5IPE.SEWE1 RECONNECTION 0 COMMERCIAL
<br /> MULTIPLE ESTIC WATER SERVICES REQUES
<br /> DOMT WATER SERVICE�TYPE 1 SIZE((Ircle:desired size)
<br /> 'Q i AM DECLINING Iy1ULTTIPLE DOMESTIC'WATER SEI VICE ,FbR ' 0 CIoMESTIC: 314", 1", r, OTHER;
<br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP,. CI IRRIGATION: •314", 1". 2", OTHER:
<br /> Q I AM OPTING TO INSTALL.MULTIPLE DOMESTIC WATER 0 FIRE: r, 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 R,EVERSESIQEOF rHIS',FORM:
<br /> 1 .
<br /> CONTACT INFORMATION
<br /> OWNER NAME: 1,tL�r yc* TENANT;NAME(If Commercial):
<br /> OWNER MAILING•% tDRESS steer 4'Z4. el i ,. :.t , pee:LK,, AN/
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<br /> vGir .=l;i- sT.A.; v.,,l l 4ili"?(> f3
<br /> OWNERPHONE: 4 25 , I .05sz,-yp 'OWNER EMAIL:
<br /> CONTRACTOR NAME:-Th� Drva.1 irt .bo C'I c- i. 1 A C.
<br /> CONTRACTOR ADDRESS: . STREET i'. '00 O07tie1 ,.fist, .:�Iek, ' t'�L.I ` 1o', „I E
<br /> 'CRY Mb., Csem. { zIP 1&PrZ.
<br /> CONTRACTOR PHONE: "r• - '✓`""! •.:C'7 " CONTRACTOR EM:iAIL: I i - lee ra t vt—lo - .rte+ t
<br /> CONTRACTOR IJP.,#(REQUIRED) DAA i rJ 00 9.12 IA I-I CITY OF EVERETT BUSINESS Lie..S#REQUIRED} Z 361 I
<br /> RIMARY CONTACT, CI OWNER . ,CONTRACTOR Q OTHER(Please Specify) ..
<br /> CONTACT NAME: CONTACT PHONE: ,A.12„.. . IAN. -.-1 ,[
<br /> abe e,.)- W41"0,; CONTACT EMAIL;
<br /> AGREEMENT-The undersigned appliceni agrees to.goinaN alth all provisions of the Everett Municipal Code T`ttta 14 Water end Seweror such other nllesandregulations now '
<br /> existing or which maybe established from Vine to time,The applicant furtheregiees,as condition precedenttoreceiving sers+lce/hat the utilitiesdivision shall have the right,at any t
<br /> time without notice;to shut offor turn on the water supply forrepairs,;construction,and nonpayment et charges or for any etherreasenabie cause,I am the-owner,,ori am.
<br /> mitigated by the owner of this property to perform the work for which appticatiorr,•is made,and 1 comply with the State Contractors Law 1827 RCW and 298,200A WAC.
<br /> City of Everett'Ohicial Rise Only '
<br /> PERMIT#
<br /> rIzed nt$maure gatet
<br /> s pevised 912 312 0 1 5.) ,. - 't.
<br />
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