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ATE*, / 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.govlpermits
<br /> PROJECT SITE INFORMATION
<br /> PROJECT ADDRESS:3/2 C 0,lIe S Ave.
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ODULEX ❑MULTI-FAMILY-#OF UNITS: ❑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 /> ❑ 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: /6i y C,,, TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET 3/.2 p A,k 3 Ave /�
<br /> CITY sirs L„24 ZIP -{5 0/
<br /> OWNER PHONE: 0'— '3'~ 33.31 / OWNER EMAIL:
<br /> CONTRACTOR NAME:.,.���,`�.`.._.,. /�zc.hn>�o�;c.4... .. . ... ...... F .. __.......�. ....s..,,.,_r�.. -. .... .Y..,-. .- ., .. _.,.�,._...,_ w,,..-,.,... . .., .�__. ..,
<br /> CONTRACTOR ADDRESS: STREET. ) S 23" p
<br /> CITY SC��wc. STATE ZIP lG�vet
<br /> CONTRACTOR PHONE:ZvC270 CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): /�6(,TZ&CS/�z CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 53 2 4-I
<br /> ..s:__:�_.T___._..�.r a. .,:� __._...._s, ....::.,.µ..._,r.,__,... n�.. #x.,...w __,w=, u_.v�R. ».s_ ,._..,., ,T..,.,,r T...:T_�_, anti,. �a .. ,..: .___..
<br /> PRIMARY CONTACT: ❑OWNER CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: 2S3. ,g-plgU
<br /> C 4.s /11.,„*t t,f_ CONTACT EMAIL: c@
<br /> frmar-71tec� Cor-,
<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 maybe established from time to F
<br /> time.The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have
<br /> cg
<br /> the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and 10-DO
<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 1 comply with the State Contractors Law 18.27 PERMIT#
<br /> RCW and 2 . 00A WAC
<br /> A lax 2/ he .. .. ( 30a -ao _ _-
<br /> OwnerlAuthorized Agent Signature Date (Revised 10/12/2015)
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