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WATER / 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.gov/permits
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<br /> PROJECT ADDRESS: 2-6 Oct r-uc\ger-- Ng_
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: ❑SFR ❑TOWNHOUSE 511-DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑ACCESSORY.
<br /> CHANGE OF USE? �NO 0 YES, FROM TO
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<br /> �/ SEWER(check all that apply) WATER(check all that apply)
<br /> 11S-IDE 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: (provide calcs to support size choice)
<br /> ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR 0 DOMESTIC: 03/4" 01" 02" ❑Other:
<br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. 0 IRRIGATION: 03/4" 01" 02" ❑Other:
<br /> ❑ 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
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<br /> OWNER NAME: AAg 'I i TENANT� pNAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET '2�40'7p /10�1�eir Avim-- \Q� y'f/�
<br /> CITY (144,T/ STATE 'UM—
<br /> `M ` ZIP 9O C�' I
<br /> OWNER PHONE: 206"Li( 1 8gO3 OWNER EMAIL:
<br /> CONTRACTOR NAME: Mk >,/,1rAil-1"�9
<br /> CONTRACTOR ADDRESS: STREET 222 I cl '74-
<br /> CITY “Y+614- STATE W V ' ZIP cryo Zo
<br /> CONTRACTOR PHONE: Z06 -:791-/-751% CONTRACTOR EMAIL: I'/c(k r h , pl Aivo f Vv-4 ;I. C dl-v1
<br /> CONTRACTOR LIC #(REQUIRED): ( S q 0 K- CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 0s22 73
<br /> PRIMARY CONTACT: ❑OWNER CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: •
<br /> CONTACT PHONE: 2067 ! --7S,/.7,n J
<br /> gWin C\ 1 y(li t l CONTACT EMAIL: etoLAv, llo/v1 r�" Ai/ . C ofre\
<br /> AGREEMENT-The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title 14 Water and Sewer of such other rules and regulations now
<br /> existing or which maybe 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 /> PERMIT
<br /> City# of Everett Official Use Only
<br /> U � to15O3O
<br /> Owner/Authorized Agent Signature Date (Revised 10/12/2018)
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