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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 FAX 425-257-8857 I (E)everetteps@everettwa.gov I https://everettwa.gov/permits
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<br /> PROJECT ADDRESS: aim 9 efi8 94:6
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<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: 21FR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑ACCESSORY
<br /> CHANGE OF USE? ❑NO ❑YES, FROM TO
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<br /> f SEWER(check all that apply) WATER-.(check all that apply)
<br /> NJ 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 /> ❑ IAM 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 /> TI■NFOR nAti t M Mkt, k S q 5
<br /> OWNER NAME: Ar").44/10,(1 be a_V)2.-e1/4 TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET 91409CS/W.8+00+ S'}'- /� v�
<br /> CITY .{�`(� STATE filal4 ZIP q8 CP
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME: SOLY441 v J - - PI,m blcvi
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<br /> CONTRACTOR ADDRESS: STREET t--10I S vJ 146-13K-A,
<br /> CITY Se—fa'"Q+ //�� STATE t f'* ZIP s
<br /> CONTRACTOR PHONE:eg(6 q 3 a - r-rY-7 CONTRACTOR EMAIL: N/A--
<br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED): Q 3eiO3Qy
<br /> PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR El-OTHER(Please Specify) el vnbeA
<br /> CONTACT NAME: CONTACT PHONE: CC,,,t1 a (-7 ---t)S 9
<br /> r e-y1.1 &() CONTACT EMAIL: 4r ° r i end edJ a, ;G.( eLewn
<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 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!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 /> G ��c
<br /> 1106//9
<br /> Owner/Authorized Agent Signature Date (Revised 4/1.5/2019)
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