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<br /> WATER I E UTILITY AP*LICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT,WA 98201
<br /> (P)425-257-8810 j FAX 425-257-8857 (E) everetteps@everettwa>gov www.everettwagov/permits
<br /> PROD CT SITE INFORMATION
<br /> PROJECT ADDRESS: /04 6� �, Co, c- (r6 t 1 /4c/ ,1 WA—
<br /> IF
<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 DINDUSTRIAL
<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 /> IDE 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: TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET
<br /> CITY STATE ZIP
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME: FC1 v . Sc
<br /> mq
<br /> CONTRACTOR ADDRESS: STREET s2 3 �( k
<br /> CITY-r>,.errer STATE\J ZIP 43.( Z. d
<br /> CONTRACTOR PHONE(L�S) c 37i60. CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): / 00 )Z I6Q CITY OF EVERETT BUSINESS LIC.#(REQUIRED):12. (Q rj
<br /> w..v,..-��,,.,,.,.>A...�..t�..�x�,..�,.,�,>.a,...m.,,. �., ..,-.,:.w,�......�..�,..w.�_..,_...�.,.��,�`�...t�x�,..,.,,�..z,�.�.n,..,.�....�..w,n,,.....�,..,�.�....�M.�.,.K,,,...,.�.� .�w.,l. .>a.�,�.,,�.>��.�..:. .x_��,v.�. .,=w�.-,..�,�.�.:..,.�..,�•
<br /> PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE:
<br /> 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 DD
<br /> the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and 3 f
<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 296.200A WAC. } i(6t, b^006
<br /> e A Date (Revised 10/12/2015)
<br /> Owner/Authorized Agent Signature
<br />
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