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4677. WATER / 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 1 (E)everetteps@everettwa.gov I www.everettwa.gov/permits
<br /> r �y N Ixt !I $F 1101'P1+1 +1 y 1
<br /> PROJECT ADDRESS: /g 2 / 7 3 I 1> 5+-1— c —
<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 ❑INDUSTRIAL
<br /> CHANGE OF USE? 0 NO 0 YES, FROM TO
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<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> SIDE 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 /> ❑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 /> OWNER NAME: TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET 7 .‘2 l (b S'� .
<br /> CRY STATE ZIP
<br /> OWNER,PHONE:,,, OWNER EMAIL:
<br /> CONTRACTOR NAME: 0 y'7 (A/e1ct A)4J s At ,a44-1,)QC-('c-
<br /> CONTRACTOR ADDRESS: STREET 'Pt� (3 l� C G i � �J�j�
<br /> s-----(;:eziti,9-77�' CRY ^� �1 STATE CAjZIP ( m ?q
<br /> CONTRACTOR PHON57'3153- ( 70 CONTRACTOR EMAIL: �Q
<br /> �\ _--
<br /> CONTRACTOR LIC #(REQUIRED) 1 ��� (� ��(�'* '' .CITY OF EVERETT BUSINESS LIC.#(REQUIRED)
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<br /> PRIMARY CONTACT: 0 OWNER ONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: 2�� /0-0 3 c�
<br /> -,..&.lL \e�� CONTACT EMAIL:
<br /> AGREEMENT:The undersigned applicant to comply with all provisions of the Everett Municipal Code Title 14 Water and Sewer or such other rules and regulations now
<br /> 9agrees
<br /> existing or which may be established from time to time.The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have the right at any
<br /> time,without notice,to shut off or turn on the water supply for repairs,construction,and nonpayment of charges or for any other reasonable cause.I am the owner,or 1 am
<br /> authorized by the owner of this property to perform the work for which application is made,and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC.
<br /> City of Everett Official Use Only
<br /> ilif_AiiipI / PERMIT# • ,
<br /> lit/ Y -ZC� (3 UOH0-12
<br /> Ow . .uthorized Agent Signature IMF Date (Revised 9/23/2016)
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