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41 ---11°' ' . ATE / E UTILITY APPLIC> TIO
<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@everettwagov I www.everettwagov/permits
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<br /> - :: ' zPIROJECT SITE INFORMATION% 3 -S-,:>i,
<br /> PROJECT ADDRESS: i 9, i(® ( 3L:-,c,/ • 5 T. 5-6 E Ve&Tit WA . eZn3
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: A, SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL El INDUSTRIAL
<br /> CHANGE OF USE? A NO ❑YES, FROM TO
<br /> UTILITY APPLICATION INFORMATION '
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> iii.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 /> 0 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 /> 0.1 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: ${{-ANMI DN L 1 I YLl . b() !e TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET ` 4,/ ! 3 rK • 5�• c
<br /> CITY '1V 1-1 STATE tA/A„ ZIP qO 2,01
<br /> OWNER PHONE:VA%)552—.3 560 33PCO OWNER EMAILA kqe)~fnn' �'�(7 A- ,.. ry1/,�>„ . ;,
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<br /> CONTRACTOR NAME: —�-P. C CFCCS"pa In Cil
<br /> CONTRACTOR ADDRESS: STREET j //�-'" r i4/�� !",,
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<br /> CITY .,_, e-n- " STATE o4- ZIP I R/o 3
<br /> CONTRACTOR PHONE:CL06)‘52.-% 0 CONTRACTORIEMAIL: �(Ct ro in÷-1(3j 1:14)
<br /> CO £ O Puoty"
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<br /> CONTRACTOR L1C.#(REQUIRED): rC c L 6 �� Q ill CITY OF EVERETT BUSINESS LIC.#(REQUIRED): P/Olielt,
<br /> ....
<br /> PRIMARY CONTACT: 'OWNER 0 CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: 2,6A,55 2 --35-C6
<br /> IIISON3 ` t.:1 ( CONTACT EMAIL:as re,VIP C) j„.4„.4--PCr�dGm�0 ,/ ,C
<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 FEE
<br /> time.The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have n O 0
<br /> .'
<br /> y 0
<br /> the right at any time,without notice,to shut oor turn on the water supply for repairs,construction,and
<br /> off
<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 wo w ich application is made, nd I comply with the State Contractors Law 18.27 PERM #
<br /> RCW and 296.200A C. K (elig U �t o -O\(—
<br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015)
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