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WATER / SEWER UTILITY APPLICATION
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<br /> 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 www.everettwa.gov/permits
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<br /> PROJECT ADDRESS: '7 a �,cIzII -� 1, Ost, CG
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: ,JR-DETACHED ❑SFR ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? O ❑YES, FROM TO
<br /> .UTILITY 06#111 ATIO0704:1 R44#0:
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> /SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION
<br /> O 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 ❑ DOMESTIC: 3/4", 1", 2", OTHER:
<br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ 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 FORM.
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<br /> .: �,..�.e CONT,--ACT,#40:004110:: ,.. . . .. __ ._.,. . .. . _
<br /> OWNER NAME: ei < 14'b tits TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET 7 , r.
<br /> P (A-'L CITY STATE il)C0 • ZIP 6_.1,D(
<br /> OWNER PHONE: OWNER EMAIL:
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<br /> CONTRACTOR NAME: i!/f y{,t S'��e% t IA
<br /> CONTRACTOR ADDRESS: _STREET ?D_
<br /> CITY �t/le� STATE (!t/GQ_e ZIP I'5/.. Co
<br /> CONTRACTOR PHONE: 4/4,25 02 5 9.13/ CONTRACTOR EMAIL: `(p l ui 574,4?�u ca.I vka e l It t
<br /> CONTRACTOR LIC.#(REQUIRED)• tjo� 5� F.rN CITY OF EVERETT BUSINESS Lle2(REQUIRED):.b6,7. Y3
<br /> PRIMARY CONTACT: 0 OWNER kCONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: £/, S ..23 g ciSa (,
<br /> C-kt >;(` V 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 maybe established from time to FEE
<br /> time.The applicant further agrees, as a condition precedent to receiving service that the utilities division shall have V)0
<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.l am the owner,ort 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 PER I (((
<br /> RCW and 296.200A WAC. / r ' I O- 0()
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<br /> Owner/Authorized Age Signature Date (Revised 10/12/2015)
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