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WATER SEWER UTILITY APPLIATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> -,— . 3200-CEDAR STREET, EVE .ETT• 98201 <br /> :. '. `h,n ar-1.-'l 4rw+r.'r WA. .. - } <br /> (P)425-257-8810 I FAX 425-257-8857 I (€)everetteps@everettW9 gov I www everettwa.gov/perrnit <br /> r .. , .,,4 : ��t.�Ate-� ._ ',,1::‘3.7f..;,- �„��,�� .,� 'r�gi ,t . < ,., ... <br /> PROJECT ADDRESS: 1 L1'?Cit, S. - <br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# l <br /> BUILDING TYPE: i9SFR fTCOWNHOUSE• `:DDLIPLEX .0ADU• (MULTI-FAMILY-#OF 1:I�IITS:; fG0MMERfli IAL ACCESSORY'! <br /> 1CANE OF USE? 0 NO D YES, FROM Tt? <br /> SEWER(check all that apply) WATER(check all that apply) <br /> !✓J SIDE SEWER REPAIR .0 NEW WATER SERVICE INSTALLATION <br /> 0 SIDE SEWER ALTERAilON D;C.OMfsLETE-SERViC 0-METER-ONLY <br /> "0 NEW SID SEWER INSTALLATION SERVICE/METER USE: <br /> D INSTALL BACKWATER VALVE(outside the building) D SFR <br /> D SIDE SEWER CAP-OFF 0 MULTIFAMILY-#OF UNITS: <br /> D SIDE SEWER RECONNECTION D COMMERCIAL <br /> MULTIPLE DOMESTIC,WATER SERVICES REQUEST WATER SERVICE TYPE I SIZE:(provide catcs to support size choice) <br /> ❑I AM DECLINING MULTIPLE b:OMESTIC WATER SERVICES`FOR D DOMESTIC: 03/4 01” D. � DOther: <br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑IRRIGATION: 0314" ❑t" 02"; DOther <br /> D I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER 0 FIRE: 01"_" D2" 04" 06" 08" ❑Other: <br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER 0 DOMESTIC/FIRE COMBO: 01" 02" DOther: <br /> SINGLE OWNERSHIP.FILL ODD REVERSE SIDE OF THIS FORM. 0 BACKFLOW PREVENTION(Outside): ORPBA ❑DCDA DDCVA <br /> OWNER NAME jrt C3JX"'t 1—ft,,, 1 YY': I S TENANT BUSINESS NAME(1f Commercial): <br /> OWNER MAILING ADDRESS STREET Uti)edrn. !^y } <br /> ., e,vej-� STATE > d `. 4Ip 9 ez J <br /> OWNER PHONE: (2`9 C) & ,) ., . OWNER EMAIL: B)+ �. ,11• c -r <br /> ,..CONTRAOTQFt NAME::' ,sp <br /> nstar 1 1 .C.... � . Mr. <br /> CONTRACTOR ADDRESS: STREET $.�r04� w_ <br /> oily i.'e. z STATE .. :ZIP <br /> CONTRACTOR PHONE:�C) i tOs-k - 't 17 CONTRACTOR EMAIL: <h{ X" c s�> �Q_C: <br /> CONTRACTOR UC (REQUIRED) 00(2„)e-02.220, tCITY OF EVERETT BUSINESS UC.#(RE,C UIRF1) cOi - ... <br /> PRIMARY CONTACT: 0 OWNER CONTRACTOR 0 OTHER`(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: c ) <br /> a ' CONTACT EMAIL: <br /> AGREEMENT 7 he rrriderstgned appIIcant a' es to comply with all'provisions of the,EVerettillitanicipal Code Title 14 Water and Sewer or such other nates and regulations now <br /> existing or which may be estabilshedIrom 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 offor tunr on he water supply for repairs,construction,and nonpayment;of charges or for any other reasonable cause.<i am the owner,ort am <br /> authorized by the owner of this property to perform the work for whichapplication 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 /> i PERMIT 4, <br /> � , 03 :, ff <br /> i <br /> . . et/Authorized Act, t Signature 41 ate (Revised 10/1212018) <br />