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WATER / SEWER UTILITY APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> EVERETT
<br /> 3200 CEDAR STREET, EVERETT, WA 98201
<br /> WASHINGTON (P)425-257-8810 I FAX 425-257-8857 1 (E)everetteps@everettwa.gov I https://everettwa.gov/permits
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<br /> PROJECT ADDRESS: S /3 , ��5T V`E,.
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: iVSFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑ACCESSORY
<br /> CHANGE OF USE? ild-NO 0 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 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 /> ❑ 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 /> CONTACT"INFO tllilATION t _ ..,
<br /> OWNER NAME: `I b k A C( ( )SO TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET SCJ` V � ST A-l ✓E �
<br /> CITY �/ore STATE /W O` ZIP(n
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME: D 0� .....
<br /> CONTRACTOR ADDRESS:/ STREET (9.3) 1 7f k A-i)
<br /> CITY Ste, STATEA/A ZIP `t c'LV V
<br /> CONTRACTOR PHONE: p ��pp CONTRACTOR EMAIL: �q
<br /> CONTRACTOR LIC.#(REQUIRED):8000 Rs L� ♦ ♦ R. CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 0.3778
<br /> PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: t/ 3 a. R 7O 6
<br /> Rick `1•4-co5+k x 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 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 /> <;?/24-f g--/ 2- P67)
<br /> Own r/Authoriz Agent Signature Date (Revised 4/1.5/2019)
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