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WATElit� / SE , .ER uTiLirt APPLICATION
<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 /> PROJECT.SITE INFORMATION
<br /> _
<br /> PROJECT ADDRESS: 4[23
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ODULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL DINDUSTRIAL
<br /> CHANGE OF USE? 0 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 /> ❑ 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. ❑IRRIGATION: 3/4", 1", 2", OTHER:
<br /> ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑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: A for, , hoer/e TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: sTREET
<br /> CITY STATE ZIP
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME:
<br /> �� C„,_,.../edi,..,,lG ; 5..,..... ........ .._.,11,..« .. ......<.�...._.=F _T,_..v..a-. ..., .-,.r._.. .., <. ... ...w.......:_ u.... ,.��. .,_._ .<,...,
<br /> CONTRACTOR ADDRESS: STREET( ! S S �S I 7"1S! J �f e/&
<br /> CITY }��../r.-Z STATE i. I1T ZIP ` t
<br /> CONTRACTOR PHONE:2.0(2-2,5'3-52 70 ((,, CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC./f(REQUIRED): f/ fCO 7Z&4 Sh Z CITY OF EVERETT BUSINESS LIC.#(REQUIRED): ' ' <3241
<br /> .,�.K..,,.::...._.,,:,.,.:,
<br /> PRIMARY CONTACT: ❑OWNER 71 CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: 2 3 -Sag_c46o
<br /> rCONTACT 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
<br /> nonpayment of charges or for any other reasonable cause.tam the owner,or 1 am authorized by the owner of this
<br /> property to perform the work for which-ap 'ation is made,and l comply with the State Contractors Law 18.27 PERMIT#
<br /> RCW and 296.200A C. �D \ �v 02.
<br /> 41/.2°//5
<br /> Owner/Authorized Agent Signature Date (Revised 10/1212015)
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