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® WATER / SEWER UTILITY APPLICATION
<br /> ♦i
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> EVERETT
<br /> 3200 CEDAR STREET, EVERETT, WA 98201
<br /> WASHINGTON (P)425-257-8810 1 FAX 425-257-8857 1 (E)everetteps@everettwa.gov I https://everettwa.gov/permits
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<br /> -�Hxe.. �� ```',"s . b £. u'h'+4FaM•x�-'.... ���.w .., ns.Rx``
<br /> PROJECT ADDRESS: all 0 g+4, sT
<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 ❑YES, FROM TO
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<br /> ��:x �
<br /> WER(check all that apply) WATER(check all that apply)
<br /> SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION
<br /> ❑SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY
<br /> .,E = - INS :LLATIOk 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 /> 5tI 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" ❑1" 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 /> OWNER NAME: L„�� NSep^ TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET a310 Q ST )�
<br /> CITY vet/ e STATE�V e, z,,9896/
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME: Ro QIocri r
<br /> CONTRACTOR ADDRESS: STREET 3�'.{a t 7-I h l� 1)�. 5 rT
<br /> CITY ro Y\ le STATE ZIP cig s
<br /> CONTRACTOR PHONE: 2S 3 a.- ' 7c$6 CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED):j T oeSCi, CITY OF EVERETT BUSINESS LIC.#(REQUIRED): (mss
<br /> PRIMARY CONTACT: 0 OWNER I'`.ONTRACTOR 0 OTHER(Please Specify) Q
<br /> CONTACT NAME: i �',•f` CONTACT PHONE: z/ a S .3 a 3706-I4e k
<br /> RIC 24-04,5÷r�~ kris km/ CONTACT EMAIL: � 6 g/0 Sa3'1 kr is'S
<br /> AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title 14 Water and Sewer or such ofher 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 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 /> /6/47e."1:: :-,„-L
<br /> s� a�, U1 ED€ ' Dk (
<br /> ner/Authorized Agent Signature Date (Revised 4/15/2019)
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