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WATER / SEWER UTILITY APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> EVERETT 3200 CEDAR STREET, EVERETT, WA 98201
<br /> WASHINGTON (P)425-257-8810 I FAX 425-257-8857 I (E)everetteps@everettwa.gov I https://everettwa.gov/permits
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<br /> PROJECT ADDRESS: /2- 9 — $,4
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: El COMMERCIAL ❑ACCESSORY
<br /> CHANGE OF USE? EO 0 YES, FROM TO
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<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> INSIDE 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
<br /> OWNER NAME: c"lu/> iZ 6 TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET /Z 37' ✓,ez 4-CITY STATE 6'44' ZIP M
<br /> 7-03
<br /> OWNER PHONE: 7 2 - �� �f OWNER EMAIL:
<br /> CONTRACTOR NAME: 4 / ✓ 7— e "9" c:-2 ;c7 -
<br /> CONTRACTOR ADDRESS: STREET 4"2 .l/ cc: 3 2'
<br /> CITY STATE 6"...6..."/:
<br /> "... ~ ZIP C:7lee::>
<br /> CONTRACTOR PHONE: CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): L/ Gr �—B—�ZdIP CITY OF EVERETT BUSINESS LIC.#(REQUIRED): /15
<br /> PRIMARY CONTACT: '2 OWNER 0 CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: yZ 5-- 060 -- 1/5
<br /> pa,e6 , CONTACT EMAIL:
<br /> AGREEMENT:The undersigned applicant agrees to comply 11 provisions of the Everett Municipal Code Title 14 Water and Sewer or such other rules and regulations now
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<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 p= . 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 /> 41111,P° e /6.1 e. PERMIT# orA
<br /> ,1460K 11,139
<br /> Owner/Authorized Agent Signatur• Date (Revised 4/15/2019)
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