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11 is 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: , — EircKwyk, yar
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<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: IgSFR ❑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 /> `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 /> C JNT`ACT INFORMA lO1
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<br /> "OWNER NAME: V V L.. fPrf-k- V�, TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET 2'3 '_. CI, re c i Nay t .
<br /> CITY Eve • vSTATE k..)0......, ZIP `) l
<br /> OWNER PHONE: �j O OWNER EMAIL
<br /> 'A CONTRACTOR NAME: Y1 k>Jcvti\I- i,
<br /> CONTRACTOR ADDRESS: STREET \10��{�-. �,S9�'�'
<br /> CITY � � STATE /00 ZIP CI S(56 l
<br /> CONTRACTOR PHONE:Zotoa _I 2040 CONTRACTOR EMAIL: 1/4y �r f C>i C"'I #111PI l l I
<br /> CONTRACTOR LIC.#(REQUIRED)fl ` p s , , ITY OF EVERETT BUSINESS LIC.#(REQUIRED):164. ' 4 J
<br /> PRIMARY CONTACT: 0 OWNER - '% CONTRACTOR 0 OTHER(Please Specify)
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<br /> T NAME: CONTACT PHONE: Le) - ---3.42 �4��
<br /> O� ��� CONTACT EMAIL: 'fl )„,,,,......\,_n onplui h ,
<br /> AGREEMENT:A
<br /> undersigned applicant agrees to comply with all provisions of the Everett Municipal Cod©itle 14 Water and Sewer or such other rules and regulations now r
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<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 o 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
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<br /> PERMIT#
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<br /> Own-r/AuthorizeInt Signature Date (Revised 4/15/2019)
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