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WATER r SEWER UTILITY APPLICATION
<br /> 44°11Y-!:-."---
<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 1 www.everettwa.gov/permits
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<br /> 9 OJ 477"SITE INFOR ATION- , :"� . ,, ...,
<br /> PROJECT ADDRESS: (ray l..Q m ij 0:IA 6 )er . ' i1 9' ,o/
<br /> IF APPLICABLE: ❑OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: ZSFR-DETACHED ❑SFR-ATTACHED ❑DULEX 0MULTI-FAMILY4OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? ,E NO 0 YES, FROM TO
<br /> UTILITY APPLICATION INFORMATION >' ,,lY
<br /> b .. `.. �°�._ ; .. . �.3 ...;. ..p.+s-.i?�,�Y`i.4 h..L!^;<,...wa_szavc.'�-t:4.�a's:. .+ar.e,�,rrz �xu'.+�ssw-...:�.� ....w.�a....-� ,.... ...-,a.. $.,� ':��R. ..`� � .. 4t'.,,.}..7r.
<br /> .may .
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION
<br /> ❑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 /> ❑.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 ItiiFORMATiON
<br /> OWNER NAME: c(ciAA_C -.U ti-ale e TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: )STREET C`124( L-"1-4beard
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<br /> CIN 2.\( STATE 11-12. 4�yyc
<br /> . ZIP i O O I
<br /> OWNER PHONE: 1P.5." a. 37 (.03(O i OWNER EMAIL:
<br /> CONTRACTOR NAME: f`v tif u( 3 tad r I J. 1- , -1,--
<br /> CONTRACTOR
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<br /> CONTRACTOR ADDRESS: -STREET 1 • 0, a 6 3i--
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<br /> CITY G�(1J�'Jl STATE 0QJ( z,'(, l5 G
<br /> CONTRACTOR PHONE: ya, .ti.s-9 gig( CONTRACTOR EMAIL: tOtir�ustadrefU/Kb;v YI�h '�C e
<br /> f wi� it 05 CITY OF EVERETT BUSINESS LIC.#(RECIUIR D):e pig /C{
<br /> CONTRACTOR LIC.#(REQUIRED): t,,,� .,e.. ,. � �4.
<br /> PRIMARY CONTACT: 0 OWNER CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: ti a 5 ,:,23 7 53 e?.6,
<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 %x" �_
<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!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# r..4RCW and 296.200A WAC 1 1 3
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<br /> Owner/Authorized Agent gnature Date (Revised 10/1212015)
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