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#10110z--. WATER / SEWER UTILITYI A I'414
<br /> 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.gav/permits
<br /> PROJECT SITE INFORMATION
<br /> PROJECT ADDRESS: \')) V i I V\ \.Lc)
<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 ❑INDUSTRIAL
<br /> CHANGE OF USE? Y1,122 ❑YES, FROM TO
<br /> . - N
<br /> UTILITY APPLICATION INFORMATION,
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> QkSIDE 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) ❑ SFR
<br /> ❑SIDE SEWER CAP-OFF ❑MULTI-FAMILY-#OF UNITS:
<br /> ❑SIDE SEWER RECONNECTION ❑ COMMERCIAL
<br /> MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE: (circle desired size)
<br /> 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:\in/0),C -IbtAiP4TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET
<br /> CITY STATE ZIP
<br /> OWNER PHONE: OWNER EMAIL:
<br /> ..,..w » a,,._, R ...._ ....» »_»M....,, s» a» ,,, , .,___ _ .,,, » »,,
<br /> CONTRACTOR NAME: A,vk p
<br /> ilAitidk
<br /> CONTRACTOR ADDRESS: STREET 1 \/
<br /> Y
<br /> CITYeAtoreit
<br /> STATE WA . ZIP
<br /> CONTRACTOR PHONE: ®' CONTRACTOR EMAIL:alt./0,tAlift bf t l7 !
<br /> CONTRACTOR LIC #RE UIRED CITY OF EVERETT BUSIN LIC #REQUIRED
<br /> PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: . CONTACT PHONE: (.,142' )cin-i6121
<br /> — 21
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<br /> CONTACT EMAIL: / u� f ( le, O 4
<br /> I .0_40,0
<br /> AGREEMENT-The undersigned applicant agrees to comply with all provisions of the Everett Municipal I ode Title City of Evert 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, a con iti precedent to receiving service that the utilities division shall have �'lY✓
<br /> the right at any i e,7jtho t noticto shut off o turn on the water supply for repairs,construction,and 4.3
<br /> nonpayment f cr s or or an other reasona /e cause.lam the owner,.or am authorized by the owner of this
<br /> property to p or (he wo r, hich applicatio is made,and I comply with the State Contractors Law 18.27 PERMIT#
<br /> RCW and 29 200 WAC ' ter- 1 bi -621
<br /> Owner/AuthorizAgent Signature Date (Revised 10/12/2015)
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