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7 / SEWER UTILITY CLIC T1 N <br /> ��� CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT,WA 98201 <br /> (P)425-257-8810 I FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: p Ave.. oip ell- <br /> IF <br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 B LDING AREA SF 0 LOT# <br /> BUILDING TYPE: ❑SFR DETACHED ❑SFRATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑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 /> ❑SIDE SEWER REPAIR ❑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 /> ❑ 1 AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR 0 DOMESTIC: 3/4", 1", 2", OTHER: <br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ IRRIGATION: 3/4", 1", 2", OTHER: <br /> O 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 /> OWNER NAME: TENANT NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET <br /> CITY STATE ZIP <br /> OWNER PHONE: OWNER EMAIL: <br /> 30ONTRACTOR NAME: ( G. I(V <br /> CONTRACTOR ADDRESS: STREET 1,,q g6-14 5e <br /> +V 4 , / 1 . 'f 'k 3 <br /> CITY STATE [ ZIP <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> CONTRACTOR LIC.#(REQUIRED) CITY OF EVERETT BUSINESS YLIC.#(REQUIRED): <br /> k— -y — __ <br /> PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 0 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 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 <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 /> RCW and 2 00A WAC. U ^�2 <br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015) `J <br />