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kiLI 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: 36011 i.' c Ave...
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: pSFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑ACCESSORY
<br /> CHANGE OF USE? L?NO 0 YES, FROM TO
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<br /> �. .�x K i_ `mac 3 �' '�Sr` .: 110:0 0 1 l 4 8
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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 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
<br /> CONTACT INFORMATIIO
<br /> OWNER NAME: /C6,.y io vice-to TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET
<br /> CITY STATE ZIP
<br /> OWNER PHONE: ZGG-35 3-7i,3`f OWNER EMAIL:
<br /> CONTRACTOR NAME: Fr,'ci'i t��ilna//4.2e & 1
<br /> CONTRACTOR ADDRESS: STREET 24 12 S /L-40.6 5 Il p (J/f{
<br /> CITY 5e.'.. 7'«.G_ STATE 1.41 ZIP y p l 5
<br /> CONTRACTOR PHONE: .206-Lc�'c 21 a / CONTRACTOR EMAIL: f a
<br /> CONTRACTOR LIC.#(REQUIRED)f/nQ t607.1.
<br /> ?l �S6 5/..;7' [CITY OF EVERETT BUSINESS LIC.#(REQUIRED):5,2 l
<br /> �• K, Fes;. �• � ur::�
<br /> PRIMARY CONTACT: 0 OWNER to CONTRACTOR 0 OTHER(Please }Specify)c�
<br /> CONTACT NAME: CONTACT PHONE: Z,j -50 — o4 &)
<br /> G G',, If(2n /72 CONTACT EMAIL: c Mon-ie,,,v.e,(D/f 'tG
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<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.)3'rform the work for which application is made,and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC.
<br /> f City of Everett Official Use Only
<br /> PERMIT#
<br /> , /// r U Vak.o - �t6
<br /> Owne/Authorized Agent Signature Date (Revised 4/1.5/2019)
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