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44itiw / SE E'` UTILITY - -Ii PLICATION
<br /> "111° . 11-7ER � I
<br /> , OF EVERETT PERMIT VICES
<br /> 3200 CITY CEDAR STREET, EVERETT,WA 98201
<br /> (P)425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov 1 www.everettwa.gov/permits
<br /> PROJECT SI`Z'E INRMATON` `� . _$I
<br /> PROJECT ADDRESS: 1j �Y AO!, f K y....a../�FO()k i ---t,
<br /> 10 \�(�YSF 0 LOT#
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS '� BUILDING AREA / 70-6
<br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED \`
<br /> 1 DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑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 SEINER ALTERATION AI COMPLETE SERVICE 0 METER ONLY •
<br /> ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE:
<br /> ❑ INSTALL BACKWATER VALVE(outside the building) 'R SFR''Aktip',Q,,(
<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 )kI DOMESTIC: 41310 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: A7N 4 f, ./,‘,A,,,/,„,„ /z C TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET "P. 0 to cmc 7`(.
<br /> CITY r=�v
<br /> STATE W 'T ZIP 727L.0 C'
<br /> OWNER PHONE:,,. Z .y Z Zy—_ls .akr
<br /> M.OWNER EMAIL:� y1w9,:fr
<br /> )ij �j6m f.1 k�fInt`�w� il
<br /> / . l_..,_CONTRACTOR NAME: D yM /
<br /> 15j �"'�((j a b„ P r /,// C.
<br /> CONTRACTORADDRESS: STREET / ,J- !�.>'L.
<br /> CITY STATE ZIP
<br /> CONTRACTOR PHONE: tf 2_s---(("2 2 - /e CONTRACTOR EMAIL: • _cG ar_c c"---a
<br /> CONTRACTOR LIC.#(REQUIRED) _µ_gN ,----------------------CITY OF EVERETT BUSINESS LIC.#(REQUIRED): m —v e
<br /> PRIMARY CONTACT: 0 OWNER n)'CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: y2_5--_ z 6, /_ j vs- 6
<br /> D a.A l T-eM d CONTACT EMAIL: ,rna_.5- o`.<e S GI C !0 e',/ cra
<br /> /
<br /> AGREEMENT.:The undersigned applicala grees 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 *� �0
<br /> the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and _J,�ll ' 6 I 6 ,2
<br /> nonpayment of charges or for any other reasonable cause.I am the owner,or I am authorized by the owner of this
<br /> property tope orm the work for which application is made,and I comply with the State Contractors Law 18.27 PERMIT#
<br /> RCW and 29 OOA WAC. �� �� D� /
<br /> I( ed1O/ O15)
<br /> Own rl t or ent SignatureL'��
<br /> 121
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