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WATER / SE E UTILITY APPLICATION
<br /> r"F-- . 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 I www.everettwa.gov/permits
<br /> PROJgC ' SITE INFORMATION • , _LL i
<br /> PROJECT ADDRESS: //VQ " p‘ esi
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: ❑SFR-DETACHED FR ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: 0 COMMERCIAL 0 INDUSTRIAL
<br /> CHANGE OF USE? .,,, 11-6 0 YES, FROM TO
<br /> UTILITY APP
<br /> LIGATION INFORMATION �
<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 /> ❑ EW SIDE SEWER INSTALLATION SERVICE/METER USE:
<br /> GCI 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: 314", 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 /> CONT ACT INRM
<br /> FOATION... .:'
<br /> ,���
<br /> OWNER NAME: 6� '�'1� ..I n TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET I LI 61 Qee �JU►e-7 e�
<br /> CITY 'eVeY N STATE ' �JZIP ""/-133
<br /> OWNER PHONE:,........ ...a w..w,,. .. .....0 ,..,. ,,,wOWNER EMAIL:
<br /> CONTRACTOR
<br /> ,_..,.v,. ... ..x..YN.4....,.....••-• .......,„.a.Mw..w.,....,.7N.,..,.,....»wM»•,..,..,..N. ,....,..,W ki.,..,�
<br /> •
<br /> CONTRACTOR NAME: l �L 9 11
<br /> CONTRACTOR ADDRESS: STREET NG 0 -
<br /> CITY ��,�eSTATE � �jr�
<br /> ZIP Y V
<br /> 13104131041CONTRACTOR PHONE: '1311 3CONTRACTOR EMAIL: �q\ S �i�IUJ C\( i . eo vv..
<br /> etif)
<br /> VA/' CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 512,43
<br /> VAC--1
<br /> PRIMARY CONTACT: 0 OWNER
<br /> CONTRACTOR LIC.#(REQUIRED): C ��CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE:
<br /> 30d._
<br /> 0d._ $3?a
<br /> ” v�4A3�C/ CONTACT EMAIL: \ eCO l.0.e,r p1,u m
<br /> _Co/Vt.
<br /> AGREEMENT:The undersigned ..'ant agrees to comply with all provisions of the Everett Municipa ode Title City of EvSett Official Unly
<br /> e
<br /> 14 Water and Sewer or s - other rule-and regulations now existing or which may be established from time to FE
<br /> time.The applican ,'h .- ees, as condition precedent to receiving service that the utilities division shall have
<br /> the right at an e •ithou otice, o shut off or turn on the wafer su•.y.for repairs,construction,and ;'----
<br /> nonpayme• of c•-rges• for a otherreaso.-• - -. -. am the owner,orI am authorized by the owner of this --
<br /> property o pe '•rm --work :; pplication is made,and!corn/ply wit the St la Contractors Law 18.27 PERMIT#
<br /> RCW an. For
<br /> /9'' I 1 U 1 at _ `OI 0� 14 \
<br /> Owner!, thorize. -•ent Signature Date (Revised 10/12/2095)
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