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WAR / SEWER UTILITY AALICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> EVERETT
<br /> 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: �a I 1 ORA. hoes-, 7 K FL41- t. .1 7f27 1
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: ❑SFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑ACCESSORY
<br /> CHANGE OF USE? 0 NO 0 YES, FROM TO
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<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> ASIDE SEWER REPAIR 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 caics 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 INFORMATION ... .. ,
<br /> OWNER NAME: f7Lt r, �`///A— TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET asc77- 014 „,�._ D/T
<br /> CITY E%G 1/� STATE CA/.4 ZIP1y�O
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME: ,--ihzi �”, S y C�"'' s 7 / i,� S,v/ k ►--
<br /> CONTRACTOR ADDRESS: STREET 4/U//� /��, /I <-9
<br /> CITY 'f2rJF-1,04, „ STATE L✓24- ZIP yfpl4. )
<br /> CONTRACTOR PHONE: Qs-.g70-.2' CA( CONTRACTOR EMAIL: 4.3., /ri,A,.,.,6;w Qy 7 P , (,
<br /> CONTRACTOR LIC.#(REQUIRED): //27J /5�`GG JC,I,TY OF EVERETT BUSINESS LIC.#(REQUIR ): l0
<br /> PRIMARY CONTACT: QWNER 0 CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: Vile-s 70 _as 4 c.
<br /> CA—
<br /> L.,' Z�°� CONTACT EMAIL: 4.1,..,d.e0r) G.�-.S, ,7 "7 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 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 /> PERMIT#
<br /> '7./ 2/,„,p U n‘O
<br /> 0 orized Agent Signature Date (Revised 4/15/2019)
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