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WATER / SEWER UTILITY A'-*P UCA T IO
<br /> /11. 1'71 ---1,./-41 CITY OF EVERETT PERMIT SERVICES
<br /> vv-`'r- 3200 CEDAR STREET, EVERETT,WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857 I (E) everetteps@everettwa.gov I www.everettwagov/permits
<br /> s ` PROJECT SITE U1FORPJ ATJOIdf' z. . ...
<br /> PROJECT ADDRESS: '6(1r7 �,pi,� ,(,.rte 1 e, c�) > t/✓ 203
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL 0 INDUSTRIAL
<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 /> 1.41 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 /> ACT INFORMATION
<br /> CONT .,. . . .`
<br /> OWNER NAME: ,r,,, CPC0\i,t,r- TENANT NAME(If Commercial): �.`�i
<br /> OWNER MAILING ADD SS: STREET C.v L le6 L- kmic r- , 4�E' Gni I �•
<br /> eV�J /
<br /> eCt+I-V CITY 41 11 STATE ZIP, 2.0.5
<br /> OWNER PHONE: OWNER t-+ EMAIL: . .,. v ., -. .....M.. w k. .
<br /> .M1,:...aw..,=.,,,.,....w..,l.._.,M,:...I.N.., .. 4.p,.....W>L,,._....),,,,,nS4.�.,.O.. W,, .._... )) .. Y„.., ,.,...w ..,,.,..,.."•,.•. vN,...,.:� R .v,.u..... w Q
<br /> CONTRACTOR NAME: &,G,p✓� 4'c 1 '•'— � Q.Q It'u �©O1 —
<br /> CONTRA TO DDRESS: STREET L..I(e c l40 /¶ ..� E. 6 }
<br /> CITY itivotiji Tt7l�t STATE V”•� ZIP WZ1 Vit
<br /> CONTRACTOR PHONE:(Zl ) 162.) CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): 4 2.,9 O ivl CITY OF EVERETT BUSINESS LIC #(REQUI•ED)A3 2.1-A,
<br /> PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR 0 OTHER(Please Specify) '
<br /> CONTACT NAME: CONTACT PHONE: C G70) .b — /./icl Z i
<br /> glie4:19A-
<br /> / _A 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 . VO
<br /> the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and 4' ® (
<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 I comply with the State Contractors Law 18.27 PERMIT#
<br /> and 296.200A WAC. f U i' ,10 - O -1)
<br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015)
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