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izi WATER / SEWER UTILITY APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> EVERETT 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: aa AWUcq N.vi) . br =rr k\ 9 4I
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: EISFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑ACCESSORY
<br /> CHANGE OF USE? 1 'NO ❑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 ❑COMPLETE SERVICE ❑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" ❑1" 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: Di" 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 /> T CONTACT INFORMATION
<br /> . av
<br /> OWNER NAME: SUZ.N. .te- 1Ki.:T5C TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET a a5 A'YE &,oa 61,4D . t,n pp
<br /> 8
<br /> CITY 2 I Err STATE J1 ZIP I
<br /> OWNER PHONE: 2ok-6i79- OWNER EMAIL:
<br /> CONTRACTOR NAME: RSV pi-uiliM&
<br /> CONTRACTOR ADDRESS: STREET y/QC? '-110NF. w Al
<br /> CITY SEa"in.,✓ STATE (Al A Q ZIP 9 v 10
<br /> CONTRACTOR PHONE: 2O6— (033—/700 CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): g$T PQiL S13 C O [CITY OF EVERETT BUSINESS LIC.#(REQUIRED):S 9
<br /> PRIMARY CONTACT: 0 OWNER c-CONTRACTOR 0 OTHER(Please Specify)
<br /> C1:\* TACT NAME: CONTACT PHONE: a0(,_ q02-(cks y
<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 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 th owne 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 /> 6,-I7/q t U \otoco- oq
<br /> Owner/Authoriz' Agent Signature Date (Revised 4/15/2019)
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