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<br /> 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: Z IV Li /V 441
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: 1&FR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑ACCESSORY
<br /> CHANGE OF USE? kgrNO .0 YES, FROM, TO
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<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> Fl 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: _#$ 0,5 v//i vw y TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET -/"Oel 1 gA
<br /> CITY L'1- STATE e.i.,/c' ZIP
<br /> OWNER PHONE: i'Z- Z?—Z9iy OWNER EMAIL:
<br /> CONTRACTOR NAME: P7 ,-1 4493 Zi C.
<br /> CONTRACTOR�E {ADDRESS: STREET 4/6/0 Z Z 3 4'-'1S1—S 4-4-1."9/41.-"4ie Zb��� CITY STATE 41.....i 2 ZIP 7 il)73
<br /> CONTRACTOR PHONE: Zoo-ZIs'- 3 y 3 - CONTRACTOR EMAIL: ia/vjs1 ,Dios 4vrs«s4 -
<br /> CONTRACTOR LIC.#(REQUIRED): VO/vni 6 9 330 CITY OF EVERETT BUSINESS LIC #(RE6 UIRED):
<br /> PRIMARY CONTACT:AnalVtaLCR ( 'CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: 2vta-Z-TT- 3 ti 3.5---
<br /> $(i . /11i.`1-4 CONTACT EMAIL: p/tm,16 pies 0 4C „4,..42
<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 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 tum 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/comply with the State Contractors Law 18.27 ROW and 296.200A WAC.
<br /> City of Everett Official Use Only
<br /> PERMIT#
<br /> ,6. _� y,--/? /r U VA.C4 — 0 (40
<br /> Owner/Authorized Agent Signature Date (Revised 10/12/2018)
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