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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 1 FAX 425-257-8857 1 (E)everetteps@everettwa.gov 1 https://everettwa.gov/permits
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<br /> PROJECT ADDRESS: c-r(y 7 f (3 et✓vt 0 b
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: gSFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑ACCESSORY
<br /> CHANGE OF USE? %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 ❑.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 /> CONTACT INFORMA�'TI O N
<br /> OWNER NAME: CkYklaO-VV Cr6 TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET e+c07-�t t3i YnOn ZD
<br /> CITY! -r`+� STATE ZIP 9. ZLJIS
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME: E(IrUO_ - 1
<br /> CONTRACTOR ADDRESS: STREET gll/270 (� /L` '2-P c
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<br /> CITY r ( STATE A- ZIP / 5'17.e---(
<br /> CONTRACTOR PHONE:ZC(9r-—7 t`b' "Z-17 0 CONTRACTOR EMAIL: 7-1.1` l t') r G , C c�Y✓�
<br /> CONTRACTOR LIG.#(REQUIRED): ?tb ' c3' CITY OF EVERETT BUSINESS LIC.#(REQUIRED):
<br /> PRIMARY CONTACT: 0 OWNER CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME:—fT((.4 ��� 1,� CONTACT PHONE: —(..0(.0— �—Z 1-7 0
<br /> Y `t CONTACT EMAIL: -\ 7 - (1 zj`�
<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 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 /> 150 Pub en-
<br /> ou. o
<br /> Owner/Au orized Agent Signature
<br /> ( Date (Revised 4/1.5/2019)
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