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,. <br /> - -- WATER I SEWER UTILITY APPLICATION <br /> ,/""liti --' <br /> ,1�►'' a. 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.gov/permits <br /> PROJECT ADDRESS: 04 It- SU) M ' ■ .i /A / .'? /t <br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# <br /> BUILDING TYPE; OSFR-DETACHED ISFR-ATTACHED EJOULEX OMULTI-FAMILY#OF UNITS: OCOMMERCIAL I: INDUSTRIAL <br /> CHANGE OF USE? 0 NO 0 YES, FROM TO <br /> SEWER(check all that apply) WATER(check all that apply) <br /> El SIDE SEWER REPAIR v, NEW WATER SERVICE INSTALLATION <br /> 0 SIDE SEWER ALTERATION <br /> OMIaLETE SERVICE 4/01:101226, <br /> CI NEW SIDE SEWER INSTALLATION SERVICE/METER USE: <br /> 0 INSTALL BACKWATER VALVE(outside the building) 0 SFR <br /> 0 SIDE SEWER CAP-OFF 0 MULTI-FAMILY-#OF UNITS: <br /> 0 SIDE SEWER RECONNECTION 0 COMMERCIAL <br /> MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE I SIZE:(circle desired size) <br /> 0IAMDECLINING MULTIPLE DOMESTIC WATER SERVICES FOR 0 DOMESTIC: 3 1", 2", OTHER: <br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. IRRIGATION: 3/4", 1", 2" OTHER: <br /> 0 I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER 0 FIRE: 1", 2", ", 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 /> grr 4t4virveak. n . t o v..l A ,V a s ,� m 02. T L r .. p {�i4,-i ,; 5, .?. <br /> s <br /> OWNER NAME:M/4) _ Leap 1,0. A TENANT NAME(If Commercial):pW „,...5.7a., <br /> OWNER MAILING ADDRESS: STREET L •m' : Al ,, _. i i Q M+p <br /> OWNER PHONE: e, <br /> s Ail,-•ra oWNEREMAIL 1YtkF4i►wt1 27(0a r •6rn <br /> NAME: 4.-2 A • • it ° E Irtl r;� n10 • ]i C...,, <br /> R ADDRESS: STREET 1 IliN <br /> ' ...' ©Ff.IGC <br /> CITY ' 1 STATE OP., ZIP <br /> CONT-RAG•TEIR PHONE. i; •�Li r r 11 CONTRACTOR EMAIL: /: ��./! u <br /> `_ z_ To {s • I- • a CITY OF EVERETT BUSINESS LIC.#(REQU RED <br /> PRIMARY CONTACT: 0 OWNER 04401114PlifiiTieR CI OTHER(Please Specify) ___ _ t7 / ��/ __._ i %__ <br /> CONTACT E: / 04/2„ CONTACT PHONE: r`' ,!r , , <br /> 1 • CONTACT EMAIL: a�1 � t^ /L i <br /> AGREEMENT'The und=signe.applicant agrees to comply with all provisions of the Everett Municipal Code Title 14 Water and Sewer or such other rules and regulations now <br /> existing or which may be established from time to time.The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have the right at any <br /> time,without notice,to shut off or tum on the water supply for repairs,construction,and nonpayment of charges or for any other reasonable cause.I am the owner,or!am <br /> authorized by the owner of this property to perform the work for which application is made,and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> PERMIT# <br /> U c '7 C( ,Ida/4 Kr-JX-12-- /C4/21//7 001 <br /> Owner/Authorized Agent Signature Date (Revised /23/2016) <br />