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WATER / SE E \ UTILITY APPLICATION
<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 ( www.everettwa.gov/permits
<br /> PROJECT SITE INFORMATION
<br /> PROJECT ADDRESS: .S'8 I c kc$ Qc
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: ❑SFR-DETACHED I SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? C NO ❑YES, FROM TO
<br /> UTILITY APPLICATION INFORMATION
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> tg SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION
<br /> 0 SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY
<br /> O NEW SIDE SEWER INSTALLATION SERVICE/METER USE:
<br /> ❑ INSTALL BACKWATER VALVE(outside the building) 0 SFR
<br /> 0 SIDE SEWER CAP-OFF 0 MULTI-FAMILY-#OF UNITS:
<br /> ❑ SIDE SEWER RECONNECTION ❑COMMERCIAL
<br /> MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE I 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: �.G�N h kc, TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET \201 Qc kcS
<br /> CITY C' '•G j-‘ STATE ZIP
<br /> OWNER PHONE: (12S -S 5 - 17 8 3 OWNER EMAIL:
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<br /> CONTRACTOR NAME: yh{c�nO ( '`{aro(CCl1 (JJP ��.rCJ��C S V d\.\(\,
<br /> t(I n P f
<br /> CONTRACTOR ADDRESS: STREET 370 7- Sf2�a ���,� �.(j p
<br /> CITY Y::�`-` e / i STATE Ui4 ZIP 7O 20, '
<br /> CONTRACTOR PHONE: y25 4{22 ” 2C5- CONTRACTOR EMAIL: VOctiCr-WCt ,S prU111 J(n LC foe UYI
<br /> CONTRACTOR LIC.#(REQUIRED)• ?)11-• CITY OF EVERETT BUSINESS LIC.#(RE•. RED k. r
<br /> PRIMARY CONTACT: 0 OWNER IN-CONTRACTOR 0 OTHER(Please Specify) nA•��,
<br /> CONTACT NAME: CONTACT PHONE: 'f25- y2 2 - (3 6'S
<br /> M1 ct iNcici / f
<br /> CONTACT EMAIL: wo,^i�-WaAt, v•o,�lns[-�(�& 51.„0 CC)Nt
<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 3C)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 /> RC . 96.200A WAC.
<br /> a, ) - U _ o0
<br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015)
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