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ATE I SEWER UTILITY fA`PP UCATION
<br /> ,:111111
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT, WA 98201
<br /> (P)425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa,gov[ www.everettwa.gov/permits
<br /> PROJECT`SITE INFORMATION
<br /> r :_
<br /> PROJECT ADDRESS: Z 1 ( •
<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 0 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 /> *-0 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 I SIZE: (circle desired size)
<br /> ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR ❑ DOMESTIC: 3/4", 1", 2", OTHER:
<br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ 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 /> . .
<br /> *OWNER _::.DWNER NAME: a.. Vu/ TENANT ME(If Commercial):
<br /> OWNER MAILING ADDRESS: , TREET ` n sC "-^'
<br /> ' � n
<br /> ( / STATE �(fjJj
<br /> OW11-7,,,NER PHONE: . .cc' 1 OWNER EMAIL:
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<br /> CONTRACTOR NAME:
<br /> CONTRACTOR ADDRESS: STREET .
<br /> CIN STATE ZIP
<br /> CONTRACTOR PHONE: CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED) X „r ��_ �rtF ry � a CITY OF EVERETT BUSINESS`LIG.#(REQUIRED):,..k„...,,,_„,,_______.,,,,,,„._
<br /> PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE:
<br /> CONTACT EMAIL:
<br /> AGR' MEN .The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title City of Everett Official Use Only e
<br /> 14 ater and'ewer or such other rules and regulations now existing or which may be established from time to FEE
<br /> tim=.The app!! ant furthera ees, - a condition p cedent to receiving service that the utilities division shall have
<br /> the ight at an time,witho t"e,t.shut off o n on the water supply for repairs,construction,and O r
<br /> non.: -nt• cha•.es or-fo y other reasonabl c. .e. :m the owner,orI am authorized bythAowner ofthis
<br /> property!. •:'for t l;or'<fe which applicatio e, d 1 comply with the State ontraPERMIT#
<br /> RCW and e•.200 '; 1 ,) J u $65...,,
<br /> 0
<br /> Owner/Auth. ized Agent Signature Date (Revised 10112/2015)
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