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4477 WATER / SEWER UTILITY 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.everettwagov/permits <br /> l PROJECT SITE INFORMATION z <br /> PROJECT ADDRESS: 2)0 C I a( (,1 �/J p j c 66 UP � t +-1- W Lk q 6j-c <br /> IF APPLICABLE: ❑OUTSIDE CITY LIMITS 0 BUILDING AREA SF ❑ LOT# <br /> BUILDING TYPE: ❑SFR-DETACHED OSFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OFUNITS: ❑COMMERCIAL ❑INDUSTRIAL <br /> CHANGE OF USE? gr-NO ❑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 ❑ COMPLETE SERVICE 0 METER ONLY <br /> ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: <br /> O INSTALL BACKWATER VALVE(outside the building) 0 SFR <br /> ❑ SIDE SEWER CAP-OFF ❑ MULTI-FAMILY-#OF UNITS: <br /> ❑ SIDE SEWER RECONNECTION 0 COMMERCIAL <br /> MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE: (circle desired size) <br /> ❑ IAM 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 ❑ 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: pc,)-(._ oC\L3-5 O 'n TENANT NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET 3064 0t-9kiAlc)1 L 131.0 p <br /> � CITY STATE �� ZIP �L- j <br /> • <br /> / <br /> OWNER PHONE: "(z 5` �i�o 1 - ��7I� OWNER EMAIL: <br /> CONTRACTOR NAME: R D#c) �m C y''' <br /> CONTRACTOR ADDRESS: STREET 6/6227?6 / (�. k "7k— <br /> /1; STATE � 1 ZIP 9 g a- ( <br /> CONTRACTOR PHONE:Z o o- 1r2,0\-„, 1-z.-5c <br /> 1;5-Zi 7D CONTRACTOR EMAIL: <br /> CONTRACTOR LIC.#(REQUIRED): 1" 0 ¶5C (ZZ 6 V., CITY OF EVERETT BUSINESS LIC.#(REQUIRED): <br /> PRIMARY CONTACT: ❑OWNER \> CONTRACTOR ❑ OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: ZC3)(z2, - - Z_( C.) <br /> �� /. o ->'L� � 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 <br /> time. The applicant further agrees, as a condition precedent to receiving service that the utilities division shall have FEE .., op <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.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 /> RCW and 2 6.200A 'AC. U I ` — oc <br /> in <br /> Owne/ thzed A.nt Signature Date (Revised 10/12/2015)2 <br />