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<br /> • WOER / SEWER UTILITY A 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 www.everettwa.gov/permits
<br /> . r r �' PIiPJECT SITEIN�ORMAT'ION a
<br /> PROJECT ADDRESS: 159.6 e.)4.Its , ' ' r e' vt (,At c
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: SFR-DETACHED ❑SFR ATTACHED ❑
<br /> rot,
<br /> ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL INDUSTRIAL
<br /> CHANGE OF USE? 0 NO EYES, FROM S ►'ro'L. TO
<br /> UTILITY N 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 /> ❑ 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: :Pau Ca f Se
<br /> r) TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET I S�`p d f .e r , a en 1
<br /> CITY STATE LA �^I ZIP / O z(" 1
<br /> OWNER PHONE: 9--5-� �t7 ` s5gC• OWNER EMAIL: 04'a Cie rs'on) /4 Iva Gro/O. COGti
<br /> .,...,�...�,w....,�N.,.• > µ»»>.,w> a �ur.�.., .....w,�.w��,.,.,a�m. ,..w.�.>,.,,�,w:� ,w,,.��,.>..>�Y�uw�,..,.,.>.,..�...M.> �,....»„�w, ..m,• ..,:.�..�...,.....>M�.,.R,M�...
<br /> CONTRACTOR NAME: 11 r
<br /> CONTRACTOR ADDRESS: STREET
<br /> CITY STATE ZIP
<br /> CONTRACTOR PHONE: CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED
<br /> PRIMARY CONTACT: ADOWNER ❑CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: 1-/,2-,�_2/0 -4
<br /> CONTACT EMAIL: ' Ce, r5A,t, /G w cc90„-.k
<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 FEE30
<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 wafer 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 1 comply with the State Contractors Law 18.27 PERMIT#
<br /> RCW 6 OOA WAC. U P�
<br /> Signature Si 1 Date (Revised 10/12/2015)
<br /> 0 ner/Authorized Agent g
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