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<br /> mss------��� WAR / SEWER UTILITY —LICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> ' 3200 CEDAR STREET, EVERETT, WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857 I (E) everetteps@everettwa.gov ( www.everettwa.gov/permits
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<br /> PROJECT ADDRESS: L 0 22 c 1 5I y, S•C_ I_vett,*, I.J/\ R 8'L0
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF NKr LOT# 2,
<br /> BUILDING TYPE: ❑SFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑ACCESSORY:
<br /> CHANGE OF USE? XNO ,0 YES, FROM TO
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<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> ❑SIDE SEWER REPAIR 9 Site-MS KNEW WATER SERVICE INSTALLATION
<br /> ❑SIDE SEWER ALTERATION TIA] i 7o5.abO 'COMPLETE SERVICE 0 METER ONLY
<br /> iti NEW SIDE SEWER INSTALLATION SERVICE/METER USE:
<br /> ❑ INSTALL BACKWATER VALVE(outside the building) "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: (provi,le calcs to support size choice)
<br /> I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR fl DOMESTIC: ❑3/4" I:11” 02" ❑Other:
<br /> [[1111���`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 (DOMESTIC/FIRE COMBO: Z'1" 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: hiO t i�idt/ZSt i II olitt IAGLIS ..f./I C TENANT NAME(If Commercial): --.
<br /> OWNER MAILING ADDRESS: STREET 4 tct I2.4k" S -. S.E, �j
<br /> CITY G^VU''([�'t'4 STATE t,JA ZIP R p Z0
<br /> OWNER PHONE: Lits - 23°1, 411 Z..A OWNER EMAIL: Rod .Ct?YV\
<br /> CONTRACTOR NAME: ()WALT
<br /> CONTRACTOR ADDRESS: STREET
<br /> CITY STATE ZIP
<br /> CONTRACTOR PHONE: CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED):
<br /> PRIMARY CONTACT: %OWNER 0 CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT-1 NAME: CONTACT PHONE: qty._-to ..qq 2`4
<br /> Za kdOr✓1 CONTACT EMAIL: Rof.c9cy,le u11vx i S LA - LO M
<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 I am
<br /> authorized by the owner of this property to erform the work for which application is made,and/comply with the State Contractors Law 18.27 RC W and 296.200A WAC.
<br /> City of Everett Official Use Only
<br /> PERMIT#
<br /> S ' IC— ici U 16/.6-3-0(1
<br /> Owner/ orized Agent Signature Date (Revised 10/12/2018)
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