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#04fr�� WATER / SEWER UTILITY APPLIC ,TION
<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.govlpermits
<br /> PROJECT SITE INFORMATIOid J n ,
<br /> PROJECT ADDRESS: 7 /s` tl/.e'l-inope _
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF ❑ LOT#
<br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? 0 NO 0 YES, FROM TO
<br /> UTILITY APPLICATION INFORMATION •
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> fif 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 /> ❑ 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: 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.I.
<br /> NFORMATION
<br /> OWNER NAME: TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET
<br /> CITY STATE ZIP
<br /> OWNER PHONE: .»N . .w,.,.�. H» .v. �. u.s4.,.•...,..roln.,w OWNER EMAIL:F 44 TN- ...,,.Mw. wu. a... .. w..w,,... .»,,.0.1,pa,row.,. .n..,..�. .. .,4•-1
<br /> CONTRACTOR NAME: 2/177' I�� �r
<br /> CONTRACTOR ADDRESS: )2 q STREET f't /4,._ (hh; ,4
<br /> STATE \ A4. ZIP 95:1;
<br /> CONTRACTOR PHONE: a7f- 779. Z cJ y CONTRACTOR EMAIL:..., aopz,,„,4-kreg„,.S:
<br /> CONTRACTOR LIC.#(REQUIRED)• mr y-pc �s'6✓Z CITY OF EVERETT BUSINESS LICW#(REQUIRED): L C
<br /> PRIMARY CONTACT: 0 OWNER ACONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: yZ�- 0 70 _ Z C [�g
<br /> eC(Sn�z� .. F�J ; S CONTACT EMAIL:
<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 may be established from time to FE
<br /> time.The applicant further agrees, as a condition precedent to receivingservice that the utilities division shall have ✓f,,
<br /> 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 /> RCtN and 296.200A WAC. u v "mow o /
<br /> _ 7v�
<br /> .wwnerl/Authorized Agent Signature Date (Revised 10/12/2015)
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