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•TE: / SEWER unurie APPLICATION
<br /> Niiiwi CITY OF EVERETT PERMIT SERVICES
<br /> i� 3200 CEDAR STREET, EVERETT, WA 98201
<br /> (P)425-257-8810 J FAX 425-257-8857 J (E)everetteps@everettwa.gov J www.everettwa.gov/permits
<br /> PROJECT SITE INFORMATION
<br /> PROJECT ADDRESS: 3 3 D5- /9'04 5+- Q/2e1
<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 /> E SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION
<br /> 0 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: 0( dC.,\ fie/Sc)1// `n TENANT NAME(If Commercial):
<br /> a
<br /> OWNER MAILING ADDRESS: STREET K2/ --
<br /> CffY STATE ZIP
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME: Pow (2004--v-
<br /> CONTRACTOR
<br /> 200+--fCONTRACTOR ADDRESS: STREET 065--5 Tit Lc,)i /I q _, -1 /L/J 6 //
<br /> CITY 1-t K STATE()L ZIP 5)(1.1,'Co
<br /> CONTRACTOR PHONE: '/ Z-3 1n -C z -7 CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): (ZC 7 est- /a (3� CITY OF EVERETT BUSINESS LIC.#(REQUIRED): C 77 E•4(
<br /> ��:,,... n_ ___._._�--__.:. ,.<,___,w ._...___ .:__:._e.,..w-:. _..,.,. .t.__M..�.:.^.:_,_..n___.:..:_.,r.._=,.:.�.v.y_.__t,�...:.........:�u_____F,,.:.,._:,:. r.._._,.._.<..,,,.....,,.,::.,:..:.�:.: _n,_, ...m_..,_, _. _..,v_.,:, ...x..=__:,...-
<br /> PRIMARY CONTACT: ❑OWNER ONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: 44 Z,S- 3 4, .GY, z 1
<br /> X is 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 maybe established from time to
<br /> time.The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have FEE O°
<br /> the right at any time,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.lam 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 296.20. L / U 1%01
<br /> %®� �,0
<br /> Own• •uthorized Agent Signature Date (Revised 10/12/2015)
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