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ligli ATE / SEWER UTILITY APPLICATION
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<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.gov/permits
<br /> PROJECT SITE INFORMATION •
<br /> PROJECT ADDRESS: il,tiA fyfT t
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS ❑ BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL -
<br /> CHANGE OF USE? XII?
<br /> 0 YES, FROM TO
<br /> UTILITY APPLICATION INFORMATION
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> yi,SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION
<br /> ❑SIDE SEWER ALTERATION 0 COMPLETE SERVICE ❑METER ONLY
<br /> ❑ NEW SIDE SEWER INSTALLATION SERVICE!METER USE:
<br /> O 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: NT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET
<br /> CITY STATE ZIP
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME: 14146110, 10)
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<br /> CONTRACTOR ADDRESS: STREET 1 �,11t,Vt itre).
<br /> CITY STATE WA, e - ZIP 0,
<br /> 02*
<br /> CONTRACTOR PHONE:U'[ 0123 CO TRACTOR EMAIL: toil lir 1 ,1-11 O aChim
<br /> CONTRACTOR LIC.#REQUIRED: AT.
<br /> �� rb CITY OF EVERETT BUSIN LIC.#(REQUIRED):_,,.M .,,,,w—_ M.R . .,. .�_ .r'. ..�411 k .w..,,..,,.,w A ,.e ,,k,,.. _ .,, ..M , .,,....,..,, ., », ,. ,1 ,,,.�.,,, , ,t,n..w..N w,n . ,_ ?f�..y...,,
<br /> PRIMARY CONTACT: 0 OWNER ❑CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: • CONTACT PHONE: (.,Li? ;�G1
<br /> 2?�—9 C� 1 `
<br /> �✓�1�j M�t 1 Y�,"� CONTACT EMAIL: /� , ,, I VI/IYI.IO IND ( IC 2/410 awn!n I •e
<br /> AGREEMENT.'The undersigned applicant agrees to comply with all provisions of the Everett Municipal i.de Title \. City of Everitt 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, a con.i precedent to receiving service that the utilities division shall have 4 ,P� 80
<br /> the right at any ' e,w' . t notic to shut off o turn on the water supply for repairs,construction,and / Joe
<br /> nonpayment of ch r•-s or or an other reasons.le cause.I am the owner,or 1 am authorized by the owner of this v
<br /> property to pe•for he wo hich applicatio is made,and I comply with the State Contractors Law 18.27 PERMIT#
<br /> RCW and 29 200' WAC '� iho. u 6D- 005
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<br /> caner/Authoriz-4.gent Sig'ature Date (Revised 10/12/2015)
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