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‘AfiR / SEWER UTILITY ,i 'LICATION-4(
<br /> 4,01 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.everettwagov/permits
<br /> PROJECT SITE INFORMATION ,
<br /> PROJECT ADDRESS: 1262.6 \(o}h Ay, SES Eve-rL}} WA 911-06
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: XSFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ID 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 11430 "'C. Ft 0 NEW WATER SERVICE INSTALLATION
<br /> ❑SIDE SEWER ALTERATION s‘iSl-t_+v% P'mie.Aora^I- 0 COMPLETE SERVICE 0 METER ONLY
<br /> 11 NEW SIDE SEWER INSTALLATION re.e' SERVICE/METER USE:
<br /> ❑ INSTALL BACKWATER VALVE(outside the building) 0 SFR
<br /> ❑ SIDE SEWER CAP-OFF 0 MULTI-FAMILY-#OF UNITS:
<br /> 04 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 ❑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 FORMS
<br /> • CONTACT INFORMATION
<br /> OWNER NAME: t)catc, Pt.,c,Kara, TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET Col Q SE Egcrt,}} /v‘e,‘11 1n/'t w 3S0
<br /> CITY EVe,rb}} STATE W{1 ZIP le 708
<br /> OWNER PHONE: 425-Z3i"Ow 3(0OWNER EMAIL: Gra. k M i tarp Q MSN, (PM.�.m — ..«.. k
<br /> CONTRACTOR NAME: ?cti.C, FPc, 1-ke,ter6 1-ko'me4
<br /> CONTRACTOR ADDRESS: STREET ‘2-0 Se Ve rt,.}I- Moat J W 350
<br /> CITY CvLr4A. STATE WA ZIP 1S2.0$
<br /> CONTRACTOR PHONE: 1'1I5-2M— 5111 CONTRACTOR EMAIL: LCx.p\M,t.to (n ms N.Com
<br /> CONTRACTOR LIC.#(REQUIRED): Fa,cA Ft-Yrkw 77_ CITY OF EVERETT BUSINESS LIC.#(REQUIRED):(10°14S1' Slit
<br /> PRIMARY CONTACT: ❑` �OWNER. ❑CONTRACTOR ®OTHER(Please Specify) ?at.);n c. tik-5 c.T1'rw Maruita
<br /> CONTACT NAME: NI slyvivh CONTACT PHONE: 4'Z., -i 1-o53gt
<br /> CONTACT EMAIL: RlJan pam Fit,Ft}s 0,ctno,�'t,cr�M
<br /> AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title City o verett Official Use Only
<br /> i�
<br /> 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to FE , '7Q ,
<br /> time.The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have �/.-, s,/r 79"'
<br /> the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,arid
<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 applicatio is made,and I comply with the State Contractors Law 18.27 PERMIT# �4
<br /> RCW and 296.200A WAC.
<br /> Regan S}Klmu f . 3 1 6/ I U 1.'5°'0' — 669
<br /> OwnerlAuthorized Agent Si. ature Date (Revised 10/12/2015)
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