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T / 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 I www.everettwa.gov/permits
<br /> PROJECT SITE INFORMATION
<br /> PROJECT ADDRESS: 42,9t1 t TA VeV. 14\6.
<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? NO ❑YES, FROM TO
<br /> UTILITY APPLICATION INFORMATION
<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) ❑SFR
<br /> ❑SIDE SEWER CAP-OFF ❑ 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 /> CONTACT INFORMATION
<br /> OWNER NAME: (t MG MIA
<br /> 6 I TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET CITY Avykti/ STATE ZIP
<br /> OWNER PHONE: OWNER EMAIL:
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<br /> CONTRACTOR NAME: IA* P.4 P .
<br /> CONTRACTOR ADDRESS: STREETeAttref uri 1 Y •
<br /> CITY - - STATE\AM ® /ZIP oto
<br /> At
<br /> CONTRACTOR PHONE:U.t2A 01.2e$ CO TRACTOR EMAIL: �1 t m bl ' 1 I/ 10 .1 rt
<br /> CONTRACTOR LIC.#REQUIRED: l ,,]� CITY OF EVERETT BUSIN' LIC.#(REQUIRED): ® 5 r
<br /> PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: . CONTACT PHONE: L4S":).I2b--61(121 e •
<br /> OAA,H16 �4\ CONTACT EMAIL: A a (�1�b1�.b i ( fc RIO ' �4( .
<br /> AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal dode Title City of Everitt Official Use Only
<br /> 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to
<br /> time.The applicant further agrees, a coni". precedent to receiving service that the utilities division shall have , 1' I
<br /> the right at any ' e,w' • t notic',to shut off o turn on the water supply for repairs,construction,and .� 1
<br /> ► ✓
<br /> �,
<br /> nonpayment• ch..-r• s or or an'other reasona,le cause.I am the owner,or I am authorized by the owner of this IIII II�„
<br /> property top- or he wo • hich applicatio is made,and I comply with the State Contractors Law 18.27
<br /> RCW and 29:200 A WAC PERMIT#
<br /> re MO g
<br /> 11 \ krbi 26lb U \-1 Di...,C) ti
<br /> Owner/Authoriz- .gent Sig ature Date (Revised 10/12/2015)
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