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WATER / SEWER UTILITY APPLICATION
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<br /> EVERETT CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET,EVERETT,WA 98201
<br /> WASHINGTON (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: )ZS- E Seech 5 T ei'eeet Wig- gg60'
<br /> IF APPLICABLE: D OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: titSFR ['TOWNHOUSE ['DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ['COMMERCIAL ['ACCESSORY,
<br /> CHANGE OF USE? *10 ❑YES, FROM TO
<br /> .IJTYYAPPL1� N INFORA'riao
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<br /> 'a.. . ,_ ..£ .._ ,�^.�.,.. .x A- . .�-4,'=,0'''1--,,,,,,;,;,,',,,,, ., .. .. ,+irr W77,7 s ,.7-7,77,,,,,,77,,,,,,,,,,,, ,. . , . <.,ar, . -1,`:,,,,:`,..,--,%,-'..,,i 1,.';',-v,:
<br /> ER(check all that apply) WATER(check all that apply)
<br /> SIDE SEWER RE-AIR 0 NEW WATER SERVICE INSTALLATION
<br /> SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY
<br /> NEW SIDE SEWER INSTALLATION SERVICE/METER USE:
<br /> 0 INSTALL BACKWATER VALVE(outside the building) 0 SFR
<br /> 0 SIDE SEWER CAP-OFF 0 MULTI-FAMILY-#OF UNITS:
<br /> 0 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 ❑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 /> 41NTACT 11+ F RIVII IflI '}N '.
<br /> OWNER NAME: DOt(/) O Aiancy PU- t h TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: smEer J ZS G geeC6 5%
<br /> EVEr 7( cnY l Z✓/gsTATE q8ct& F02.0 3
<br /> OWNER PHONE: 1/25- 233 31 22 OWNER EMAIL: PUf SCh 97 e 8rna-ol,CO Pr7
<br /> CONTRACTOR NAME: DJ//0 it /7SCh er 'tines—
<br /> CONTRACTOR ADDRESS:� sTREEr 5/7cJ Eve(3reeh� So�e- P/17,6 23/ ��L.•y
<br /> ev /e CITY W6STATE XZ(f3 ZIP
<br /> CONTRACTOR PHONE: qZ$ 367- /5-t.f CONTRACTOR EMAIL: 2-fi/ePAel6`l J (�' •t��4C�i!CO'"?
<br /> CONTRACTOR LIC.#(REQUIRED) CDe li l . z0107 ... CITY OF EVERETT BUSINESS LIC.#(REQUIRED) �1 I/6�l
<br /> PRIMARY CONTACT: $OWNER ❑CONTRACTOR. 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: 6/25--3to 7- /.5.-Z/
<br /> l,Jon F)Sderiblelihe-C— CONTACT EMAIL:,;ry of eaeg(',,nsiu`,GQri7
<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 turn on the water supply for repairs,construction,and nonpayment of charges or for any other reasonable cause.I am the owner,or!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 /> 1 / fig_____
<br /> PERMIT#
<br /> l6/zq�� uIl1,D-ce
<br /> Owner/Authorized Agent Signature Date (Revised 10/12/2018)
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