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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 ( www.everettwa.gov/permits
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<br /> PROJECT ADDRESS: 415 1 o e wax/ W be d s- ci
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: *FR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑ACCESSORY I
<br /> CHANGE OF USE? )4 NO .0 YES, FROM TO
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<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:(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: Iv\t' !& IA-45.6n TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET p\5 R trSGW
<br /> CITY STATE War ZIP l p 21)3
<br /> OWNER PHONE: ,�'J �7 OWNER EMAIL: t1 - ryjAA L tte
<br /> CONTRACTOR NAME: Wp O U...0 P LunniSI IVB.'
<br /> CONTRACTOR ADDRESS: STREET /5 4.T ) 1 t Si" �& UL1 �J�_
<br /> CITY Mau jsu I`l I STATE file ZIP et%2 /V
<br /> CONTRACTOR PHONE: 212.5 • W1 ISD-1 CONTRACTOR EMAIL: delDb I et ape)tI D pt I IA' •Co hl
<br /> CONTRACTOR LIC.#(REQUIRED) A i1510 L CITY OF EVERETT BUSINESS LIC.#(REQUIRED): C) ' .�
<br /> PRIMARY CONTACT: ❑OWNER XCONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: (itch) (p• (,Lhrotn) CONTACT PHONE: 426- 44q --(0325 42-5- A 24,-.4
<br /> Core I Dr tNioblej CONTACT EMAIL: CVek b ie e. a eolto pfunk ir
<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/comply with the State Contractors Law 18.27 RCW and 296.200A WAC.
<br /> City of Everett Official Use Only
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<br /> PERMIT
<br /> J,o •- DC, 3
<br /> Own uthonzed Agent ig ature Date (Revised 10/12/2018)
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