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17 <br /> ' . `r TER / SE ''E UTILITY A*PLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> viii�- _ 3200 CEDAR STREET, EVERETT,WA 98201 <br /> (P)425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits <br /> .� PROJECT SITE INFORMATIONS i <br /> PROJECT ADDRESS: 70o5 L tvlikkU v-S� A`I L ivtuar wr g e z <br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUI,LDI G AREA SF 0 LOT# <br /> BUILDING TYPE: O5ER-DETACHED ❑SFR-ATTACHED 1 ULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL 0 INDUSTRIAL <br /> CHANGE OF USE? NO 0 YES, FROM <br /> TO <br /> 11'TIi.ITY APPLIc4TION INFORMATION <br /> SEWER(check all that apply) WATER(check all that apply) <br /> ❑SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION <br /> ZIDE 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 ❑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 /> ❑.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 FORMS <br /> CONTACT INFORMATION <br /> OWNER NAME: c(*ASH 4 S ,LC. TENANT NAME(If Commercial): POO y* <br /> OWNER MAILING ADDRESS: STREET woo,. PCIRog* AV )) Cw 2W Co - ci 3 <br /> CITY S L W STATE h ZIP get ; <br /> y <br /> OWNER PHONE: (/.061 ait"312.s 'OWNER EMAIL: TUSatig.o a Ae _,,,,,, <br /> CONTRACTOR NAME: 1,"1, Wf f QWoists1 r33 LLC. <br /> CONTRACTOR ADDRESS: STREET 11444 <br /> 4� b ti sl-1 s S <br /> CITY P4 STATE Wilk ZIP q60-7.... <br /> CONTRACTOR PHONE: q'3 46 CONTRACTOR EMAIL: az,vahruitoIiI Jt_colA <br /> CONTRACTOR LIC.#(REQUIRED): ar COL CITY OF EVERETT BUSINESS LIC #(REQUIRED): <br /> PRIMARY CONTACT: 0 OWNER E, CONTRACTOR 0 OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: ED 6mt r+14,14, ) ni-sTii <br /> CONTACT EMAIL: 5 AWL, AS m O. ,ASE, <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 Vi/aterand Sewer or such other rules and regulations now existing or which may be established from time to FE_O <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.I am the owner,or I am authorized by the owner of this —. -- _- -_- -- <br /> propertyto perform the work for which application is made,and l comply with the State Contractors Law 18.27 PERMIT# �0 <br /> RCW and 296.200A WA r ' 7-0 o / 6/i.e U ` 2O s - O <br /> Owner/Authorized Agent Sig.:.. . Date (Revised 10/12/2015) <br />