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OLT WATER / SEWER UTILITY APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT, WA 98201
<br /> (P)425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov 1 www.everettwa.gov/permits
<br /> PROJECT SITE INFORMATION:.
<br /> PROJECT ADDRESS: ()7)DZ 0OvV e,S /1 V t•
<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? ❑NO ❑YES, FROM TO
<br /> UTILITY APPLICATION INFORMATION
<br /> 1 SEWER(check all that apply) WATER(check all that apply)
<br /> ,�L 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 /> CONTACT INFORMATION
<br /> OWNER NAME: CAS- l Ol TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET 310 -2...,- l i't KR,/ A-Ni e,
<br /> cITY 2-(1L't "' STATE es- ZIP q Z 01
<br /> OWNER PHONE: 425" ito - j��Q OWNER EMAIL:
<br /> CONTRACTOR NAME: A\` S.L4colv.S e c,‘.t- \ i or ►--S
<br /> CONTRACTOR ADDRESS: STREET y. 0, --i),,,, ,r1 t,-c,
<br /> CfY c„,61„,,,,,VV‘1.4.... STATE W 43\-- ZIP cr -z 9'
<br /> CONTRACTOR PHONE: ' 2., c,•1-'Lel Z CONTRACTOR EMAIL: es5 e LLL Q Cam c - -. ,'ut�--
<br /> CONTRACTOR LIC.#(REQUIRED): LL e 5 c\ ottA CITY OF EVERETT BUSINESS LIC.#(REQUIRED): ©LA"1 Z 7-0
<br /> PRIMARY CONTACT: ❑OWNER CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: ‘A27,2(0 3. - -. 3'
<br /> SLY,i 1k 3,,,,,,,,,..4,„..... CONTACT EMAIL: CG`S_-C� Ce i,,,,c r9Sfi-. Nom'"
<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 FEEbQ
<br /> time.The applicant fu r agrees,as a condition precedent to receiving service that the utilities division shall have
<br /> the right at any time, iiout notice,to shut off or turn on the water supply for repairs,construction,and fO
<br /> nonpayment of charg•.or for any other reasonable cause.I am the owner,or I am authorized by the owner of this
<br /> property to pe .rm t -work for which application is made,and I comply with the State Contractors Law 18.27 PERMIT#
<br /> RCWand/:x:.200' �f ^ / 6\ 1
<br /> 7 ._ U '
<br /> Owner uthorized Agent Signature Da e (Revised 10/12/2015)
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