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."111111,;;;LA-' 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: /703 p,I ,t (es ,:.....
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: InhSFR ❑TOWNHOUSE ❑DUPLEX DADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑ACCESSORY
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<br /> CHANGE OF USE? +may 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: 1:11" 02" 04" 06" 08" ❑Other:
<br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER ❑ 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: M((44 A,E N t w T//X TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET 3 S/5 S 14 S f
<br /> CITY i. STATE l.R-,A ZIP ?8_c_)(
<br /> OWNER PHONE: OWNER EMAIL: NIC-(P1 t 1`f Leek a.t f.. Q.. tui i-
<br /> CONTRACTOR NAME: iU/A.. 0 (.0. f(J€&
<br /> CONTRACTOR ADDRESS: STREET
<br /> CITY STATE ZIP
<br /> CONTRACTOR PHONE: CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED):
<br /> PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: Ca 5 3 O s o(Q 93
<br /> ink I (G CONTACT EMAIL: S A-t-A(,„ ( -S /fir 0 V e_
<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#
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<br /> Owner/A thorized Agen"nat'-re _ Date (Revised 10/12/2018)
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