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ATR / E,' ,TILITY APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT, WA 98201
<br /> (P)425-257-8810 J FAX 425-257-8857 (E)everetteps@everettwa.gov l www.everettwa.gov/permits
<br /> PROJECT SITE INFORMATION
<br /> PROJECT ADDRESS: t 0' Liao
<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? 0 NO 0 YES, FROM TO
<br /> UTILITY APPLICATION INFORMVMA11ON.
<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 /> ❑ 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 INFORMATION
<br /> OWNER NAME:Ce,r�/ 04.('s C5•"/e n ,,� e�) TENANT NAME(If Commercial): 6/ ,, t, /'hr/c (-Jo 4,
<br /> OWNER MAILING ADDRESS: STREET
<br /> CITY STATE ZIP
<br /> OWNER PHONE: 1l/2c-252-OC(O OWNER EMAIL:
<br /> ..
<br /> CONTRACTORNAME: pr,-6„ ,,..., u. ..._,_,,,.,..., .. .2....,.... .M..._>,,._ .�.,..,_ ..�. ...... .. .. . ............. .�... ..,_... „a- . .
<br /> CONTRACTOR ADDRESS: STREET 2g2 5 S /54�� 4
<br /> CITY fFi��G STATE I.- A ZIP p v
<br /> /y(si)
<br /> CONTRACTOR PHONE:.)C.26-2 s 8_c270 CONTRACTOR EMAIL: y J
<br /> CONTRACTOR LIC.#(REQUIRED): --rC67"j.g S A z CITY OF EVERETT BUSINESS LIC.#/(REQUIRED): 53)4l
<br /> -1. :�. _
<br /> PRIMARY CONTACT: ❑OWNER -10 CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: �5 3-55e'g o 16 b
<br /> / /" CONTACT EMAIL: L rl0wtipve,
<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 maybe established from time to FEE
<br /> time.The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have
<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.lam the owner,or!am authorized by the owner of this
<br /> property to perform the work for which-.plication is m, -,and I comply with the State Contractors Law 18.27 PERMIT#
<br /> RCW and 296.200A WAC. / Y./7//S
<br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015)
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