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TE"- I SEWER UTILITY Al- ''-* LIC A TION
<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 I www.everettwa.gov/permits
<br /> R ITEINFOItmATION „ ,,,,,
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<br /> PROJECT ADDRESS: 17.7,1.,,,--
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<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFRATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? ❑NO ❑YES, FROM TO
<br /> UTILITY APPLICATION INFORMATION
<br /> y' . 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 ❑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 /> �t
<br /> CONTACT INFORMATION
<br /> OWNER NAME: 7(f rii Q/ f it''"lTENANT NAME(If Commercial):
<br /> ..
<br /> OWNER MAILING ADDRESS: STREET ,'SV /-9"'' 574--J-.
<br /> CITY �y e /} / STATE V/ ZIP c=79R0-3
<br /> OWNER PHONE a ,6-3.3.- OWNER EMAIL: ,,.. _ _.__
<br /> CONTRACTOR NAME: 5-,A4,77 1,c) .cii-/ 'UI ti"-
<br /> CONTRACTOR ADDRESS: STREET.9 ii O/ pi.../1,57 -7/‘‘ rr
<br /> CITY ..5"."e7-tiSTATEtr"," ZIP C7) 0 6
<br /> CONTRACTOR PHONE: ( a I I I- ` - IQCONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): 0 ?atU?0 CITY OFEVERETTBUSINESSLIC #(REQUIRED): a3103-0
<br /> PRIMARY CONTACT:n 0 OWNER x ❑xCONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: _ ) CONTACT PHONE: ' ' 7 .----9 Li a
<br /> J 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
<br /> the right at anytime,without notice,to shut off or turn on the water supply for repairs,construction,and
<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 the State Contractors Law 18.27 PERMIT#
<br /> RCW and 296.200A WAC. (g0 ,,,,;
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<br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015)
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