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<br /> TER / SEWER UTILITY 'b'PLICATION
<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.gov/permits
<br /> '. . a�t i moi. PROJECOT SITE:INFORMAT-10,,-;:4,4_,;---1,0 .b y&-6 :6:1,'!,:,3 ,.. ..i
<br /> PROJECT ADDRESS: . ''° -7l y 4 (/ .ir/G,ljf, moi!
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT -40'' 9/2
<br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? ''=!NO 0 YES, FROM TO
<br /> UTILITY APPLICATION INFORMATION
<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 /> ill 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: Dr>✓w F f"2...,e-roll TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET 3 X// - /21 ft / 5 �7
<br /> CITY F^�:^Qiv(// STATE (4...../k", ZIP TY .L G/ //
<br /> OWNER PHONE: LV.2 fir' 33 _ 3 b 3 OWNER EMAIL:
<br /> CONTRACTOR NAME: /4// '7 �,p///G, '7L� 4-4C
<br /> CONTRACTOR ADDRESS: STREET 7,..3_,2 3 /08 ,./j 5E
<br /> CITY 1/-eA741,$ STATE (....„6,..../6-7 � Z ��7f
<br /> CONTRACTOR PHONE:' ;ALIO-,7,1" 1CONTRACTOR EMAIL: AA C /
<br /> Q � /'Co L.,. to
<br /> COR LIC.#RE UIRED: 4 s �y 6 CITY OF EVERETT BUSINESS LIC.#(REQUIRED): Q 5�-1 '
<br /> CONTRACTOR ( Q ) ,�F�.��H ,�Z j� ..w,
<br /> PRIMARY CONTACT: ❑OWNER CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT N _ CONTACT PHONE: 4 a 6 " 7 7a - U k 9i
<br /> Jet' /J/z.o 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 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 "11 044
<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 /> RCS/an 296.200A WAC 6-) i —1 7 -/7
<br /> U1101,-613 1 1 0 1,-6 73
<br /> Owner/Authori Agent Signature Date (Revised 10/12/2015)
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