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E VkTER / SEWER UTILIT PLICATION
<br /> CITY OF EVERETT PERMITS CES
<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: CiI 2 v`, ,, c>„, jr.„eri/! , t
<br /> IF APPLICABLE: ❑0�OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: IIEISFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑ACCESSORY
<br /> CHANGE OF USE? O ❑YES, FROM TO
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<br /> SEWER(check all that apply) WATER(check all thaLapply)
<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 /> r51". 1 D E 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
<br /> .... .h OFTHIS FORM. 0 BACKFLOW PREVENTION
<br /> (
<br /> Outside): ❑RPBA ❑DCDA ❑DCVA
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<br /> OWNER NAME: Vi N,t,`e,- ,O A-'o " TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET
<br /> CITY STATE ZIP
<br /> OWNER PHONE: ) ckZZ OWNER EMAIL:
<br /> CONTRACTOR NAME: -Vv €3 `('t y Sle 0 eAr c-A-Ncl c'
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<br /> CONTRACTOR ADDRESS: STREET I,( v. Dr
<br /> CITY03i_,I2STATE IfVCk r ZIP CrA2O3
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<br /> CONTRACTOR PHONE:�i�'2,5)2�1'q� CONTRACTOR EMAIL: a 1,G-���'S��'LC��'�j�
<br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED):
<br /> PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE:
<br /> CONTACT EMAIL:
<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 lam
<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 /> i ,/ii.... .), ....._ /1-2/—(7 Ulgil ' Cigi
<br /> OWh i-/A i1/ ent Srgnatur Date (Revised 4/1.5/2019)
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