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WATER / SEWER UTILITY APPLICATION
<br /> #11111104 (----"t 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 z
<br /> PROJECT ADDRESS: °J( O7 Vt ? lj•
<br /> a
<br /> I2
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OFUNITS: ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? NO 0 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 0 COMPLETE SERVICE 0 METER ONLY
<br /> ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE:
<br /> El 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: p t V �,w,..,,M...,, .,�w,...,.... ,...,.....�.. .�,�,.,,�,w,. .. �. .. .:W..,.�� �w.-.,w.N,. .,...�.�, .,..,k.�,. ..,�,,...�. �.,.�...,...w...,M..
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<br /> CONTRACTOR ADDRESS: STREET �I V Ab V(/1I •
<br /> CITY eerrellt STATE W • ZIP °,02*
<br /> CONTRACTOR PHONE:04.2 )141.) OrA CO TRACTOR EMAIL: �\ Ili' 1 f O Ia• iC.('/YV t
<br /> CONTRACTOR LIC.#(REQUIRED): Le I i rt. CITY OF EVERETT BUSINr LICA#(REQUIRED)): .©51.5E(0
<br /> PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: • CONTACT PHONE: LI.{ � '9 2db - 9 2,1 `
<br /> /IAA,`/ 6 �`\ I�"l V l/ CONTACT EMAIL: /� I I✓�I�.I14I 6 c Nig f1 14L .1
<br /> AGREEMENT:TheVundersigned applicant agrees to comply with all provisions of the Everett Municipal aforde Title City of Ever 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,pi t icie precedent to receiving service that the utilities division shall have
<br /> the right at any f{n e,with° t notic-,to shut off o-turn on the water supply for repairs,construction,and 47,ce3
<br /> nonpayment 9f ch"ar bs or'or an other reasona le cause.I am the owner,or I am authorized by the owner of this
<br /> property to pe orn) he wort +r hich applicatio is made,and I comply with the State Contractors Law 18.27 PERMIT#
<br /> RCW and 29 200 WAC )(RCit \ t dIrAP1. u i01 O\ /OY. Il )'-J
<br /> Owner/Authorizgent Signature Date (Revised 10/12/2015)
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