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5 WAS ER I SEWS R U L r� Y APPLIC I1ON CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 . (P)425-257-8810 I FAX 425-257-8857 I (E) everetteps@everettwa.gov I www.everettwa.gov/permits -- PROJECT SITE INFORMATION PROJECT ADDRESS: I A'\\ 1 t IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? NO ❑YES, FROM TO y UTILITY APPLICQTIOG Ii FORGE ATi IOM SEWER(check all that apply) WATER(check all that apply) I ❑SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION ❑ SIDE SEWER ALTERATION ❑ COMPLETE SERVICE ❑ METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: NSTALL BACKWATER VALVE(outside the building) 0 SFR ❑ SIDE SEWER CAP-OFF 0 MULTI-FAMILY-#OF UNITS: 1 ❑ SIDE SEWER RECONNECTION 0 COMMERCIAL MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE: (circle desired size) ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR 0 DOMESTIC: 3/4", 1", 2", OTHER: MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. 0 IRRIGATION: 3/4", 1", 2", OTHER: ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER 0 FIRE: 1", 2", 4", 6", 8", OTHER: SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER 0 DOMESTIC/FIRE COMBO: 1", 2", OTHER: SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. CONTACT IMFORI' ATION I OWNER NAME: ' }4' ) I` ` I Lc TENANT NAME(If Commercial): (OWNER MAILING AD P RESS: STREET CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: i I 1 I i I/ /J CONTRACTOR ADDRESS: STREET /, 4111FIRELL/ J!ht • CITY VVV"""►AA STATE A, • ZIP 4/66 12,141 � ( ,/ /1/��1 CONTRACTOR PHONE:l Y[A.Ai_ Olt, CO TRACTOR EMAIL: �1 b! 1 -fl O YV 1I •I`d.d'/V I/iCONTRACTOR LIC.#(REQUIRED): r/ l 0 t t V CITY OF EVERETT BUSIN LIC.#(REQUIRED) 0 1 ;PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: (,[ ' I 9 ZS-qg�1 . Nei; \ 7 ( I a ICONTACT EMAIL: / IX1lDtQ l /W AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal 4 ode Title \- . City of Ever.t Official Use Only 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to FEEo.n time. The applicant further agrees, a con i" precedent to receiving service that the utilities division shall have ��'UV the right at any " e,w • I notice,to shut off o turn on the water supply for repairs,construction,and nonpayment• ch-r•-s or or an other reasona le cause.I am the owner,or am authorized by the owner of this property top- or he wo • hich applicatio is made,and I comply with the State Contractors Law 18.27 PERMIT# 1 RCW and 29:200 WAC k Mb ' / I p P jl�� O l —----�1 caner/Authoriz i1 gent Sig'11° Date (Revised 10/12_/2015)