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WATE / SE EE* uTiurie 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 www.everettwa.gov/permits <br /> PROJECT.SITE INFORMATION <br /> PROJECT ADDRESS: j9 9egtpi <br /> IF APPLICABLE: 0 OUTSIDE CITY1 v1ITS 0 BUILDING AREA SF 0 LOT# <br /> BUILDING TYPE: DSFR-DETACHED DSFR-ATTACHED DDULEX DMULTI-FAMILY#OF UNITS: DCOMMERCIAL DINDUSTRIAL <br /> CHANGE OF USE? D NO 0 YES, FROM TO <br /> UTILITY APPLICATION INFORMATION <br /> ����-- SEWER(check all that apply) WATER(check all that apply) <br /> LESI.DE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION <br /> D SIDE SEWER ALTERATION 0 COMPLETE SERVICE D METER ONLY <br /> D NEW SIDE SEWER INSTALLATION SERVICE/METER USE: <br /> D INSTALL BACKWATER VALVE(outside the building) 0 SFR <br /> D SIDE SEWER CAP-OFF 0 MULTI-FAMILY-#OF UNITS: <br /> 0 SIDE SEWER RECONNECTION 0 COMMERCIAL <br /> MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE:(circle desired size) <br /> D 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 /> D 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: J yie,r-) M 04,4- TENANT NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET ,p) l jilt 0y <br /> cm( Fi�/C.q-� STATE ZIP 9 ,/ <br /> OWNER PHONE: 1496 SP?. eill (c OWNER EMAIL: <br /> CONTRACTOR NAME:...., 41213.)4..tr‘ (rl9P,A„r. Pl,4.)/11Dt <br /> CONTRACTOR ADDRESS: STREET 9Cfo( <br /> Coy ' 4e 4 --� STATE f.LJE+ ZIP x..40 re <br /> CONTRACTOR PHONE:/' J / CONTRACTOR EMAIL: <br /> CONTRACTOR LIC.#(REQUIRED): 07( CC CITY OF EVERETT BUSINESS LIC #(REQUIRED): <br /> PRIMARY CONTACT: D OWNER 0 CONTRACTOR 0 OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: ((9 g59 ti/5 <br /> - hi erg 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 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 O <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 /> RC1/179.8,1200A WAC. <br /> r:.3/ S U ( V) -- _ICP' <br /> O er/Authorized A ent Si nature D (Revised <br /> 9 9 10/12/2015) <br />