|
W 'ER / SEWER UTILITY - PLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> EVERETT 3200 CEDAR STREET, EVERETT,WA 98201
<br /> WASHINGTON (P)425-257-8810 I FAX 425-257-8857 I (E)everetteps@everettwa.gov I https://everettwa.gov/permits
<br /> �� �� a ` s ����c � s.�.. �,�'.� �:�¢ y rR E c ]�1`�� :�.� wz � s�� � �5�= �''��,�;�' x� � ,,�,� yam-;-�� ap�. �� �' i� �"�4��'
<br /> o,mrI :s-.�. _.k-.;... w. v r , l'K3.ay.K". t„3'�tSlt . * Ajl of a,,. , t El£.' :i:>:F >.�_it-41: <.Y.-. � x
<br /> PROJECT ADDRESS: ScO3 0 1 S5 C �,�/ (- ct 8 1,0 3
<br /> IF APPLICABLE: ❑..OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: I�SFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑ACCESSORY
<br /> CHANGE OF USE? "4O ❑YES, FROM TO
<br /> ;;��,`x� &�.Tu.�. �' '..a. �xwj £;M1, x -�:,.xaz'^ate 3..:� svn�,�,a �,�.,�, ';S:,=F,W� � xx�^As3cp�. :_� E'� ,atL ����x*��fi'C*. Y ?._ �i���:�� � a� 3'`\.'..
<br /> fix � r 1 �',4� s ��.. �'�a � S �i �}.. �t� � _ �� +�. �'si�i- ^��`�.K..��.. �� �, � y Y ��.� .�z��
<br /> .:,Nx.�-.r„�,:-x.e..Mx :�• r...r_4.�., � y.....,:�v�t .,..�x<x,,.. `A.s..�.aa.. ..rA.t� b ��; ._>,. „ ..r,.1;,...�,�?;.�..-�,.,.a-,......... .........,.,.,..._ ..".__,.
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> XRcec,46 wig-s�t€&--(4 i «5
<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 /> iit+0
<br /> ❑SIDE SEWER RECONNECTION ❑.COMMERCIAL m / 1€. r
<br /> m
<br /> b>✓h°ha, Thr: elra:
<br /> MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE:( vide
<br /> eccalcs to support size choice)
<br /> 0 I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR I9"DOMESTIC: 03/4” L�'1" 02” ❑Other:
<br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. 0 IRRIGATION: 03/4" 01 02" ❑Other:
<br /> 0 I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER 0 FIRE: 01" 02" 04" 06" 08" ❑Other:
<br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER 0 DOMESTIC/FIRE COMBO: 01" 02" ❑Other:
<br /> SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. 0 BACKFLOW PREVENTION(Outside): ❑RPBA ❑DCDA ❑DCVA
<br /> OWNER NAME: rkkcy-K 0 2Arv�� ( 0 r"1'c.L TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET VQ D ( 0 p 4--
<br /> CITY E/'t e_ STATE /.,„f/a— ZIP ct 8 2�
<br /> OWNER PHONE: 4-1-1— 3 t � (Q I JOWNER EMAIL:
<br /> CONTRACTOR NAME: ��,� W.0 y'- S Q.,r aist.
<br /> CONTRACTOR ADDRESS: STREET S-13 4 1 c��"•Ct r.�t K �('
<br /> CITY 1/L/�.t+ STATE " /A- ZIP I U1.-0 3
<br /> CONTRACTOR PHONE: .11 C--Cy) --I 0 5" O CONTRACTOR EMAIL:‘,a�)��^ 1hCnle�{ f j d Q Je ahw.k .c an.
<br /> r
<br /> CONTRACTOR LIC.#(REQUIRED): t'A-cu lIS 9, P IL CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 43 71
<br /> PRIMARY CONTACT: 0 OWNER ONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: L{ s— 1,-7 3 - (,Q
<br /> t"C ia.1(.1 CONTACT EMAIL: a,,,T' M cn 1(7 ka) ,..1 . 0^-‘
<br /> AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title 14 Water and Sewer or such other rules and regulations now
<br /> existing or which may be established from time to time.The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have the right at
<br /> any time,without notice,to shut off or turn on the water supply for repairs,construction,and nonpayment of charges or for any other reasonable cause.I am the owner,or I am
<br /> authorized by the owner of this property to perform the work for which application is made,and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC.
<br /> City of Everett Official Use Only
<br /> PERMIT#
<br /> eV( /I cl U (' 1- 0L3
<br /> 0 ne/ thorized Agent Signature Date (Revised 4/15/2019)
<br />
|