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SEWER 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 I www.everettwa.gov/permits
<br /> - �..�/�.PROJECT SITE;INFORMATION
<br /> PROJECT ADDRESS: 1,14)240W VVI et
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL 0 INDUSTRIAL
<br /> CHANGE OF USE? rte. ❑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 /> ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE:
<br /> O 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 ❑ 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 ❑ 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 /> CONTRACTOR NAME: 17,1'1 ► p r k ,,,,•
<br /> ,,,
<br /> CONTRACTOR ADDRESS: STREET 4 I Y / .
<br /> CITY STATE VA, 0 /ZIP 61,02te6
<br /> CONTRACTOR PHONE:d.�42) ) 9,10- 011-$ CO TRACTOR EMAIL: ��v4/Or`�l I le, 1(1q •`iCAM
<br /> CONTRACTOR LIC #(REQUIRED): 4. CITY OF EVERETT BUSIN LIC.#(REQUIRED)`/ o 1 `6,
<br /> PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: • CONTACT PHONE: LIVA"I2,'1J' -�1921 `
<br /> IAA.'/ 6 PI Y�� CONTACT EMAIL: /,� / ii I imxIIi l Its 2 ioVtI t�/,i /t
<br /> AGREEMENT.:The undersigned applicant agrees to comply with all provisions of the Everett Municipal 4•de Title City of EverAlt Official Use O-nlly,• ,
<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 con.) 'n precedent to receiving service that the utilities division shall have ,( S
<br /> the right at any ' e,w' . t notice,to shut off o turn on the water supply for repairs,construction,and 4 /CJI`) ,
<br /> nonpayment f ch r•-s or or an, other reasons,Is cause.I am the owner,or I am authorized by the owner of this ✓`�
<br /> property to pe+for he wo hich applicatio is made,and 1 comply with the State Contractors Law 18.27 MI[RCW and 29:200 C '✓ IPEJI�R`\S61-
<br /> IT l�1 2
<br /> k lip
<br /> caner/Authoriz gent Sig nature Date (RPEevised 10/12/2015)
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