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0 <br /> 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.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: \ __ ( e)119•1 , <br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# <br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED 0 DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL 0 INDUSTRIAL <br /> CHANGE OF USE? Xf. 0 YES, FROM TO <br /> UTILITY APPLICATION INFORMATION <br /> SEWER(check all that apply) WATER(check all that apply) <br /> IASIDE 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 /> O 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: .11(16 YYI SWI.l� TENANT NAME(If Commercial): <br /> 1, � <br /> OWNER MAILING ADDRESS: STREET <br /> tb02 no Irv' <br /> CITY fAttoreitt STATE \AM ZIPg8 2) I <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR NAME: A-pi' P,misim,.CONTRACTOR ADDRESS: STREET p • <br /> CITY STATE • /ZIP at faz(6 <br /> CONTRACTOR PHONE:Uo Q MA CO TRACTOR EMAIL: l\ bj ''m� 1 IC E O .I <br /> # <br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINNI LIC.#(REQUIRED): 05-155-(40 <br /> PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR 0 OTHER(Please Specify) <br /> CONTACT NAME: . CONTACT PHONE: (,L1 i\)9 2?b—9(121 <br /> Ohifil; P\1 ri4I/t, CONTACT EMAIL: l � t LC �✓"61® I <br /> AGREEMENT..The undersigned applicant agrees to comply with all provisions of the Everett Municipal ode Title City of Everitt 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,,,'a con i' n precedent to receiving service that the utilities division shall have <br /> the right at any ' e,w' • t notic•,to shut off o turn on the water supply for repairs,construction,and '3D, 05- <br /> nonpayment. eh'''.-s or or an otherreasona le cause.I am the owner,or am authorized by the owner of this <br /> property top- or he wo • hich applicatio is made,and I comply with the State Contractors Law 18.27 PERMIT# <br /> RCW and 29:200' WAC ` _d U 1 b ' la <br /> D <br /> ik <br /> / lJV "/�/l Jl <br /> 1)Ccaner/Authoriz-. ••gent Sig,ature Date (Revised 10/12/2015) <br />