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WATER I SE.I `ER UTILITY A PPL1CATION
<br /> ,,,, ,r....„ _ip, .
<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% . I
<br /> PROJECT ADDRESS: 0/Q3 c�cv...„ C-1`3 ►"cVC-1 Evcdr. " WO cl- 2-c-3
<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
<br /> UTILITY APPLICATION INFORMATION
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> -1)LIDE SEWER REPAIR
<br /> 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 /> CONTACT INFORMATION
<br /> OWNER NAME: Cc.,-, v"i-e_c_../ t TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET 3 2 cs c-, fj c..1--.VV"- ��c1 A-Ue.- (__)'yy-,4 1.3 ��77
<br /> CIN Z\Cr � STATE (...-'lei' ZIP 9UZ o3
<br /> OWNER PHONE: 2.6C> 94,3- 5G 3 f OWNER EMAIL: 3G-' c-1--5 -Joe %rt_C.a t I.,Cop-71
<br /> CONTRACTOR NAME: Ire-) ✓t \- • LG.. c,,,), I) I, ‘am)0"La_
<br /> CONTRACTOR ADDRESS: STREET
<br /> CITY STATE (` ZIP
<br /> CONTRACTOR PHONE:LCs'(.,�5 .- 11 -11 CONTRACTOR EMAIL: v- -,\ eole-1C 2U )SCuoer .41C-rli
<br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 3L RO
<br /> PRIMARY CONTACT: 0 OWNER CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT`NAME: CONTACT PHONE: 20(. , ���._.'- --4-7---1
<br /> 6 4-1 t'- t-'view CONTACT EMAIL: (. .''S VI M + -av,r,J wyk.,
<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 any time,without notice,to shut off or turn on the water supply for repairs,construction,and
<br /> 3 c)nonpa .._• of charges or for any other reasonable cause.I am the owner,or I am authorized by the owner of this
<br /> pr.,.- to perform the work for • application is made,and 1 comply with the State Contractors Law 18.27 PERMIT#
<br /> RCW an. 96.200A WAC. �,--2-- 1.1Z U 1 S OS r 044—
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<br /> Owner/Authorized Agent Signature Date (Revised 1011212015)
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