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"11111d--;1 . WATER I SEWER UTILITY APPLICATION
<br /> 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 www.everettwa.gov/permits
<br /> _ 4 a r,CRN T SITE INFORMATION `a ::4 ,_. ..... .,..
<br /> PROJECT ADDRESS: .71? 2/s F1 S+
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: FR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? ❑NO ❑YES, FROM TO
<br /> _n217UTILITY APPLICATION NF,ORMATION to '',14•401#4/2:a
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> IDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION
<br /> ❑SIDE SEWER ALTERATION ❑COMPLETE SERVICE 0 METER ONLY
<br /> O 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 /> ❑ 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 /> TV _.. CONTACT INFORMATION
<br /> OWNER NAME: KC( V CT;If/ TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET
<br /> CITY STATE ZIP
<br /> OWNER PHONE:., n._..»...H tt . �..v u� . w. . .w OWNER EMAIL:.. 4.v.v .. , n� .r �, ..F.�.
<br /> CONTRACTOR NAME: !7c Oc&-
<br /> CONTRACTOR ADDRESS: STREET /CATti I/c L4- 1.31 VL j
<br /> CITY (,q t Or r/e STATE �+✓` �j c ZIP 7 r/ick,
<br /> CONTRACTOR PHONE: CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): go biescizz 6e CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 037-724/
<br /> �,.,.�„�.,.�..m....�,....�..m.,.�.m.�.,r..,..�.,.w.........,,�...�,...�,�r_,.�,..,�,�..�,o.:�....�,:a,,,,.....�._�....�.�.._,.�.._,�....�,.�.,_..e....,.Y,�..,,,._,..,�,.....a.�.�.....,..�.a..ma....�.x._.�_4...,...;........ .. �..,a..�..,.,,x,M. ....
<br /> PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: 11Z)-- 3 /gyp C )z,7
<br /> 5 CONTACT EMAIL:
<br /> AGREEMENT:The undersigned applicant 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 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 A
<br /> the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,andtai
<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 to perform the work for which application is made,and I comply with t State Contractors Law 18.27 PERMIT#
<br /> RCW and 296` U A14 - 0 G U
<br /> Owner .uthorized Agent Signature Date (Revised 10/12/2015)
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