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WATE / SEWER uriury APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> (P)425-257-8810 I FAX 425-257-8857 (E) everetteps@everettwa.gov www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: 3j1 g (--=J d 4 € <br /> IF APPLICABLE: 0,_.,//OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# <br /> BUILDING TYPE: ,LISFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY#OF UNITS: ❑COMMERCIAL [INDUSTRIAL <br /> CHANGE OF USE? WNO 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 /> ❑ 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: air, 50 yl S kale r` TENANT NAME(If Commercial): <br /> OWNER MAILING ADDRESS: sTREEr c�'ya�� � 0-69-( tie, <br /> CfIY �Ju STATE 100• ZIP eg-Q( <br /> OWNER PHONE_ 1/4157 L`f) .,.... OWNER EMAIL: <br /> CONTRACTOR NAME; 1(3 <br /> CONTRACTOR ADDRESS: STREET 01:5>( (, s <br /> CITY e4 STATE ikr ZIP Q ?D 6, <br /> CONTRACTOR PHONE: ' S ,7S9 5/3/ CONTRACTOR EMAIL:its/K(-ltctei$/2 EU I%4 L& l e't�oU��} `C'b !14 <br /> CONTRACTOR LIG.#(REQUIRED): p �frl $.� yrl RIRED) <br /> •^ e�p� <br /> � ��.... .�Q.Q.�. yin CITY OF EVERETT BUSINESS LIC.#( <br /> �� 3 <br /> PRIMARY CONTACT: 0 OWNER CONTRACTOR 0 OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: 4' j <br /> (Ct r CONTACT EMAIL: <br /> AGREEMEAIYTIie 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 /� <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.1 am the owner,or I am authorized by the owner of this <br /> property to perform the work for which application is made,and 1 comply with the State Contractors Law 18,27 PERMIT# <br /> RCW an 296.200A WAC. <br /> 1 )01 0771 <br /> Own er/Authoriz Agent Sig Cure 4 Date (Revised 10/12/2015) <br />