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WATER / SEWER UTILITY APPLICATION
<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 I www.everettwa.gov/permits
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<br /> PROJECT ADDRESS: J(E739..,4 (j 9- QQ(,i M-
<br /> IF
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: ❑SFR ❑TOWNHOUSE ❑DUPLEX DADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑ACCESSORY;
<br /> CHANGE OF USE? �NO ,0 YES, FROM TO
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<br /> �/ SEWER(check all that apply) WATER(check all that apply)
<br /> lia DE 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 /> '+a v:: vF M _. h C- : g t NtAidt i R AVLOAI� vc q. L s y va
<br /> OWNER NAME: n-4,,„ ; 1MA\ TENANT NAME(If Commercial):
<br /> OWNER M
<br /> AILINGADDRESS: STREET ']0)5 I ° 2tk- S`u)
<br /> ihmW CITY TE LOOk ZIP q W-J
<br /> c
<br /> OWNER PHONE: LC gZO )-D OWNER EMAI ( • c; VjCQ
<br /> 5e-1 ,420,61..
<br /> CONTRACTOR NAME: � � U1/4)/V-(1—
<br /> -� , � .amu.
<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: I! •WNER 0 CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: /12_5-$ Zo 2rDM
<br /> 3AVY I iN) CONTACT EMAIL: .3 rAyi A,d(\
<br /> AGREEMENT-The undersigned applicant agr to comply with all provisions of the Everett Municipal Code Title 14 Water and Sewer or such other rules anns 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 perform the work for which application is made,and/comply with the State Contractors Law 18.27 RCW and 296.200A WAC.
<br /> City of Everett Official Use Only
<br /> PERMIT#
<br /> 1(1 )."' 6 /*I_ u oc c0 (
<br /> Owner/Authorized Agent Signature Date (Revised 10/12/2018)
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