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<br /> WATER / SEWER UTILITY APPLICATION
<br /> I�►� CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT, WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857 1 (E)everetteps@everettwa.gov I www.everettwa.gov/permits
<br /> PROJECT SITE INFORMATION
<br /> PROJECT ADDRESS: 5 4. -Li/or,.,e s t
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF ❑ LOT#
<br /> BUILDING TYPE: )ISFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? ANO 0 YES, FROM TO
<br /> UTILITY APPLICATION INFORMATION
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> 14 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 /> 0 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: PA ,, /1;5 /'tc -Il oc' I TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET S4 g..,„-A8',,e S
<br /> CITY kn,fL'A STATE i k ZIP
<br /> OWNER PHONE: 4 25-32/-1307 OWNER EMAIL:
<br /> CONTRACTOR NAME:.~NP(',Gv(�... 7,,,/n_/,,,, .,...... ............_,_..,....., .. .,�......�...._.«.�.._..�...-. .... ..�_...__..,. .. ... .,_.....�....--- u..n_.�... ,p�.wr.�...
<br /> CONTRACTOR ADDRESS: STREET,28,Z.,5 $ /5.4 $1„
<br /> CITY Sec./c-4 STATE A ZIP I'g/d
<br /> CONTRACTOR PHONE:02 0 -2S '-51 70 CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): a/C07/ GkZ CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 5 324-1
<br /> PRIMARY CONTACT: ❑OWNER I CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: 2.S 3- 5.0 - O 46 0
<br /> C ,Q 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
<br /> nonpayment of charges or for any other reasonable cause.!am the owner,or!am authorized by the owner of this
<br /> property to perform the work for which appjcation is made,and I comply with the State Contractors Law 18.27 (PERMIT#
<br /> RGWand 296.200A AC� lam// o/iK J ( Si O —(03 7
<br /> Owner/Authorized Agent Signature Date (Revised 10/1212015)
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