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ER I SEWER UT000T PUUCATION
<br /> /4. -1111 ' CITY OF EVERETT PERMIT SERVICES
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<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 /> "'--:::-;. :1;01.10:1400407007,01004767.6--
<br /> PROJECT ADDRESS: I 02,0 U 'Cr
<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 ID INDUSTRIAL
<br /> CHANGE OF USE? ❑NO ❑YES, FROM TO
<br /> UTILITY APPLICATION INFORMATION
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> ❑SIDE SEWER REPAIR NEW WATER SERVICE INSTALLATION
<br /> ❑SIDE SEWER ALTERATION RCOMPLETE SERVICE 0 METER ONLY
<br /> ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE:
<br /> ❑ INSTALL BACKWATER VALVE(outside the building) 7g SFR p t4,0 l-tx
<br /> ❑SIDE SEWER CAP-OFF / 0 MULTI-FAMILY-#OF UNITS:
<br /> ❑ SIDE SEWER RECONNECTION 0 COMMERCIAL
<br /> MULTIPLE DOMESTIC WATER SERVICES REQUEST WATERCSERVICE TYPE/SIZE: (circle desired size)
<br /> ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR l3 OMESTIC: 1", 2", OTHER:
<br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ 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: r;) ,„5 / / (6. y_f / r` C TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET Pr C9 f, 0e)< 7/
<br /> CITY `7 C..1 STATE LAT C..t ZIP J�C*1A 2 P 4
<br /> OWNER PHONE: V 2- N. .ry a 2...._ // -'g- ...,.OWNER EMAIL: b. het S 6 ha 2"...-S/ ti'C.. 10,641 / 0'04 ., ,..,.
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<br /> CONTRACTOR NAME: pypf 0 s �d 6/ .e'
<br /> CONTRACTOR ADDRESS: d STREET/ .7 G /"'Q
<br /> CITY STATE ZIP
<br /> CONTRACTOR PHONE: Sq Z. CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED):
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<br /> PRIMARY CONTACT: LE OWNER 0 CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: y Z S- 2 ./. .-. ? ?vs-C
<br /> 0 4 kQ /( /J CONTACT EMAIL: r)kA As �
<br /> .ix4 ,ms , c 10S-4 4 ).(1, A
<br /> AGREEMENT:The undersigned�icant 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 maybe established from time to FE
<br /> time.The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have (\ +I. 62* �i�
<br /> the right at any time,without notice,to shut off or turn E 1 U on the water supply for repairs,construction,and
<br /> nonpayment of charges or for any other reasonable cause.1 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 PER
<br /> RCWand 296. OA WAC. U U2 621-. 4//3 r
<br /> Owned u prized e‘Signature Date (Revised 10/12/2015)
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