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ill 1.1°. ! WATE ! / SEWER uTiurf APPLICATION
<br /> .mili 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 I www.everettwa.gov/permits
<br /> PROJECT.SITE INFORMATION
<br /> PROJECT ADDRESS: 6?Aes f/ia LJ (C -( Ac. Ove g 9,?n>
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# l
<br /> BUILDING TYPE: , R-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? ,I2hI0 0 YES, FROM TO
<br /> UTILITY APPLICATION INFORMATION
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> ,IDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION
<br /> ❑SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY
<br /> El NEW SIDE SEWER INSTALLATION SERVICE/METER USE:
<br /> 0 INSTALL BACKWATER VALVE(outside the building) 0 SFR
<br /> ❑SIDE SEWER CAP-OFF 0 MULTI-FAMILY-#OF UNITS:
<br /> ❑SIDE SEWER RECONNECTION ❑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 El DOMESTIC/FIRE COMBO: 1", 2", OTHER:
<br /> SINGLE OWNERSHIP.FILL OUT REVERSE SIDE OF THIS FORM.
<br /> CONTACT INFORMATION
<br /> OWNER NAME: V.0,u-I Cossp,,� TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: /STREET [Q0(0 L,a r-pI DR.
<br /> MY ._vier STATE &JGt . ZIP cig%1
<br /> OWNER PHONE:_,Glay . 93/ _._77‘,. .r
<br /> . OWNER .....,�.�..�EMAIL:. ____,_._ ,.
<br /> . , ...�:._ .- _.,,..>.
<br /> .__ r.._
<br /> w,... ,.,>_. _
<br /> CONTRACTOR NAME: 1D j p L' ? eS Fs/4,
<br /> CONTRACTOR ADDRESS: STREET rit0, .576, 0 t� C
<br /> CITY .c t/AT STATE lQ�� . ZIP ��q.3
<br /> CONTRACTOR PHONE: 4/ e25 1 9/,7/ CONTRACTOR EMAIL: do/n,,dte sr/h b; o vi6r.•CnUy
<br /> CONTRACTOR LIC.#(REQUIRED): Hct 04.5 P jQ o 6- N1,(?)r CITY OF EVERETT BUSINESS LIC.#(RE,4f 1RED): n 9113` N`_
<br /> PRIMARY CONTACT: ❑OWNER i LONTRACTOR 0 OTHER(Please Specify) xi `�+'�'__ _� .a ,_ .
<br /> CONTACT NAME: CONTACT PHONE: I./ S %ce(c,(o
<br /> ,--------
<br /> lee y` jr l'Cr, tyI CONTACT EMAIL:
<br /> AGREEMENT:The and igned applicant agrees to comp ith 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
<br /> time.The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have FEE Q
<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. � U t �/d ,1 � 6 s r
<br /> 7�_ i c -7-41i1 i ..A �' .�(� --/ �O( l l� (tom
<br /> Own-r/Authorized Ag. t Signature ;' u Date (Revised 10/12/2015)
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