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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 I FAX 425-257-8857 1 (E) everetteps@everettwa.gov 1 https://everettwa.gov/permits
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<br /> PROJECT ADDRESS: LSO I ©a(Cc3 A.,-c % Ci 120
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: NJSFR ❑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 /> L7 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 0 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
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<br /> OWNER NAME: Cern"�/FINS r/NJtst-w ent) I . C TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET PO 06)X 7S1)I 47 p�
<br /> CITY c't'r (�(, STATE L„1-A- ZIP ceB (7,-
<br /> OWNER PHONE: LII S `7 Z S rf JOWNER EMAIL: 64.,,.tG t2 - .�.r d e::1 r ✓`eI
<br /> CONTRACTOR NAME: 5Pcx� Su,"
<br /> CONTRACTOR ADDRESS: STREET V)y AA
<br /> CITY eI'c.�`C..H'
<br /> STATE t,/1� ZIP q e4 7
<br /> CONTRACTOR PHONE: *2f 27) f 'J--to CONTRACTOR EMAIL: e'NAta 117 ('L✓J' n P1i.
<br /> CONTRACTOR LIC.#(REQUIRED): P/ .d E L/$q J s'ilt'I K. CITY OF ERETT BUSINESS .#(REQUIRED): w .
<br /> PRIMARY CONTACT: ❑OWNER CONTRACTOR 0 OTHER(Please Sped ,) ",
<br /> CONTACT NAME: CONTACT PHONE: LtLS_til3-tp
<br /> jr. S,3 ts I"Civ-ca CONTACT EMAIL: jv.si-rn e"ctvh‘t(7 rt.11, , JG't`"�c:•(, tly,s.,
<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 tum on the water supply for repairs,construction,and nonpayment of charges or for any other reasonable cause.1 am the owner,or lam
<br /> authorized by the owner of this property to perforin 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## r { `
<br /> to ft?f t U `O(O RC
<br /> O ne thorized Agent Signature Date (Revised 4/1.5/2019)
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