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WATER ISE, ,i E' UTILITY 4\PPLICATION
<br /> _ CITY OF EVERETT PERMIT SERVICES
<br /> "111111P". 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 ■ lli®JOT SITE INFORMATION; ,, -! /. r
<br /> PROJECT ADDRESS: 0 Gp 9'. -Ai f,i/'- S CU�mac--1 f C-./ , `' 9_2_4 8
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#QF UNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? ❑NO 0 YES, FROM TO
<br /> UTILITY APPLICATION INFORMATION ' '
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> XSIDE 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 /> ❑.1 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: -77 yVa h CC,-t TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET 5, O - 9,/-)../ ,4v, - e
<br /> CITY la(/(_-y-e_i^ STATE b.,/,4L ZIP 7 '2©s>
<br /> OWNER PHONE: lOWNER EMAIL',.
<br /> CONTRACTOR NAME: Ri,c_,I r /S4v f-f7ivns f ft/ 1 '.l -7
<br /> CONTRACTOR ADDRESS: STREET y p/ .S'u- ./.9.Lo-S 1-Sc C'I-
<br /> CITY S -ck_-Tp'T/G.__... STATE f /l q ZIP / e/!,
<br /> CONTRACTOR PHONE: er 6" -- J t2-TS,t.CONTRACTOR EMAIL:(.6iu,,,,,/ `S,,,, f•,u/mac- f/.,,,,b;,, - 2/ 2�
<br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.##(REQUIRED): CACIO"?
<br /> .�:...,...�..w.,.�..,a.., :�..,�.�,v, ....�.,_........., n.,,... .�...-....��,.,,r�.....w,:,.,.,�... .:.,.�..n.,:,,�.x�.,�..�..�,.y�..,...M.,�...,...�,.w..,r.k...,.W.u�,,. .�,,.:.<.
<br /> PRIMARY CONTACT: ❑OWNER CONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: // CONTACT PHONE: _ _ • _ - . G
<br /> A,,,i_ o!^ieab CONTACT EMAIL: >g,�,/,�,pmr , 19�5',��` a/f
<br /> The undersigned a licant agrees to comply with all provisions of the Everett Municipal Code Title City of Everett Official Use Only
<br /> AGREEMENT: applicant
<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 ---------
<br /> the right at any time,without notice,to shut off or tum 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 /> properly 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.izi,e_i 40YA(1/4-_.C..e. -- - 7-2///g U 1 C1403 4o
<br /> er/Authorize gent Signature ate (Revised 10/12/2015)
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