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WATER / SEWER UTILITY APPLICATION <br /> 740%1"--4 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 /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: An, WA,,I, c7 ev <br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS D BUILDING AREA SF 0 LOT# <br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL <br /> CHANGE OF USE? LNO ❑YES, FROM TO <br /> UTILITY APPLICATION 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 /> O 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 ❑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 /> ❑ 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: 5-1--e1) Ail'O1' /� TENANT NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET MA/NW\'1J h 41milhI1\5 ke r`b <br /> CITY Ift, STATEkVA ZIP ge2,1 1 <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR NAME: ' L <br /> CONTRACTOR ADDRESS: STREET 1 V liv he/. <br /> CITY <br /> STATE \AM • ZIP ot, <br /> CONTRACTOR PHONE:l.1'll A51°. <br /> ®t .1 CO TRACTOR EMAIL: p\tom b18tt//tot 1 , ®A •`ecgi , <br /> CObNTRACTOR LIC.#(REQUIRED): (�A _, CITY OF EVERETT BUSIN LIC.:#(REQUIRED) 05.1; _.:.::.a,. <br /> PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR 0 OTHER(Please Specify) <br /> CONTACT NAME: . CONTACT PHONE: (...42°S.4) i 2,b-q92,1 ��� A` /` <br /> • <br /> 9 iib i \ '1 CONTACT EMAIL: /�m( m IOI 17 1 .0 1011 1( iI •L,o <br /> AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal(' ode Title City of Everitt 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, a coni''n precedent to receiving service that the utilities division shall have } Q <br /> the right at any ' e,w' f notice,to shut off o.turn on the water supply for ('4r�[7 repairs,construction,and -„/ <br /> nonpayment. ch 7 r.-s or or an. other reasona,le cause.lam the owner,or l am authorized by the owner of this <br /> property top- or he wo . hich applicatio .is made,and I comply with the State Contractors Law 18.27 PERMIT# <br /> RCW and 29:200• WAC ,` �'D 6. 10 \?' n f <br /> J t ii <br /> (��' , <br /> ) a <br /> wner/Authoriz- ,gent Sig ature Date <br /> 1 (Revised 10/12/2015) <br />