|
milWAR / SEWER UTILITY PLICATION
<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 1 (E)everetteps@everettwa.gov I https://everettwa.gov/permits
<br /> a �- "r h > `�s�� x � sa _, c^r r ,fes■r. s.d �., �h' .:. 4fr ,k 2 .s �.
<br /> T.',�Ya..»tea.:$t"^ y 7 r `k - fie 3S?.SY 4*A }■�T d:.F ,.M'�, ;;•$k` .c'a'�v#. w `_ , i:.1 S.. i s,h. .,.,ix ri4 r
<br /> o.. .a. . .. .. .�.�.3..� .s ..'. a. �. � Y �'-\F^A,>Me> vc�'k^ci �. .,.�n, -��dw. � w,:k.a
<br /> ' PROJECT ADDRESS: 16"G?b .S 2a7 S< S‘...-
<br /> IF
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: ❑SFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: MCOMMERCIAL ❑ACCESSORY
<br /> CHANGE OF USE? 1E-NO ❑YES, FROM TO
<br /> ;,`?i lx �'�s ��F ..r�� a�al°+'r�� ;-`, �:�:�zz l -. �«,i,a�,y_�,3■,,,;�.'k .a.,>._<.�. a�t.�:.,`...u�7.ac�'e1l 5��.�a:�. ., �n�.:.a �'� .`'z+• ^s �.�5�`Ys "t �� '�� '� °�. i �:_
<br /> �Se Sl s 3 ' t,y s,a`e x J .1P ''� p.- *:,R ::§ryry���` .: p+ Ln n 3"4 x`���x x:: r
<br /> ..., s '. � q'' � �::�� �x3.'K � � x�,',::.�. � .a �..`Y.�A+I{.:Y..\�"��,.:�. '?,<.t','.?,-n�'v,a .,x�°;v��,lafly,�+�;x;:i� :skx wr...,��k£4���rn,�,.,�.., .,, . ....,,,..,. ..,..,�,:; i
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> ❑SIDE SEWER REPAIR 181 NEW WATER SERVICE INSTALLATION
<br /> ❑SIDE SEWER ALTERATION I3COMPLETE SERVICE 0 METER ONLY
<br /> C b 5'c C3-r..u-AA-rt t.24b'..-
<br /> ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: .11/4.4 SPOCts4•Cl2..
<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 caics to support size choice)
<br /> ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR IN-BOMESTIC: 03/4" 01" 02" Wther: ("
<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 /> .s,:.. . . ONTACT INFORMATION°
<br />' OWNER NAME: Fib i(,a,reautig,.F(i.. . TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET $�'ZQb-- I C C.a.
<br /> CITY V Cr STATE (.J" ZIP
<br /> OWNER PHONE: .741597 zit 243)14\ OWNER EMAIL:
<br /> CONTRACTOR NAME: RSTP4.s.c a ate S7-7Z UG►1 berit L
<br /> CONTRACTOR ADDRESS: STREET TO..Ow Tv., P ro8
<br /> l {/��
<br /> CITY c Oj PACS ft STATE W/- ZI/ ) to
<br /> CONTRACTOR PHONE: ii 2c"'TS"�'37 CONTRACTOR EMAIL: -['7 (l.a c"tQst—� , r A ii,""c
<br /> CONTRACTOR LIC #(REQUIRED) CITY OF EVERETT BUSINESS LIC.#(REQUIRED) `1 S^0
<br /> �Q_.� � ......_.:yam: (j.5
<br /> PRIMARY CONTACT: 0 OWNER VECONTRACTOR BOTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: oct(j- 6? - g b
<br /> TA.Lx- nix
<br /> PS.70 CONTACT EMAIL: KoL.vAz4,e. - a 420&AA IL( MIAGREEMENT: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.1 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 /> *obid
<br /> 44(77/f U
<br /> .Owner/Authorized Agent Signature Date (Revised 4/15/2019)
<br />
|