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1 . / SEWER UTILITY .gWUCAT1ON <br /> iriwy <br /> / . .__._ CITY OF EVERETT PERMIT SERVICES <br /> `' � 3200 CEDAR STREET, EVERETT,WA 98201 <br /> (P)425-257-8810 ( FAX 425-257-8857 I (E) everetteps@everettwa,gov I www.everettwa.gov/permits <br /> PROJMCT SITE INFORMA'T'ION, , } <br /> PROJECT ADDRESS: 50 ILI CXl 4- LuL <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 ❑YES, FROM TO <br /> UTILITY AiiPLICATION INFORMATION <br /> SEWER(check all that apply) WATER(check all that apply) <br /> ❑SIDE SEWER REPAIR 40 <br /> 45?-63- ,it-i- ❑ NEW WATER SERVICE INSTALLATION <br /> 1,-5(3o`2 ❑COMPLETE SERVICE ❑METER ONLY <br /> ❑SIDE SEWER ALTERATION il1 1 • <br /> KNEW SIDE SEWER INSTALLATIO w qt VE1Oricti4 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 ❑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 /> ❑.1 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 /> /... ..1._ t .- <br /> OWNER NAME:[..1 I C,1-1,01„-A.:‘ 5 I L£.( G G 1z..<>•'Ocsy-TENANT NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET 5a1 * - �S� t—') <br /> CITY �``J - -y-' STATE kak, ZP '2 /O <br /> T <br /> OWNER PHONE: 4-25 2- 7 9;��o OWNER EMAIL: /\/1 -1 O1� S4 L-LI. 0' cZ L 1�K`?JE T <br /> CO 5. � Q€4,- Phi_ iv/ : ( <br /> CONTRACTOR NAME: �����1 i!��(�L( 6 ��'.�Y � Sr <br /> CONTRACTOR ADDRESS: STREET <br /> CITY STATE ZIP <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> CONTRACTOR LIC.#(REQUIRED) � N �m x CITY OF EVERETT BUSINESS LIC #(REQUIRED): — U ww <br /> , <br /> PRIMARY CONTACT: `OWNER 0 CONTRACTOR ❑OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: <br /> 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 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 tum on the water supply for repairs,construction,and <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 application is made,and I comply with the State Contractors Law 18.27 PERMIT# <br /> RCWetc/296i 00AW). p I • <br /> _ ,� ogle <br /> � D <br /> I :' Af. . �' '� ..o): JAM 5/ZS l8 D i o"� <br /> ,1s1 <br /> • ner/Authorized •gent Signat� �Y (Revised 10/12/2015) <br />