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<br /> in in 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: 7 71 Vi
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: VICSFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑ACCESSORY
<br /> CHANGE OF USE? gNO 0 YES, FROM TO
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<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> ❑SIDE SEWER REPAIR amo n f ��}� 0 NEW WATER SERVICE INSTALLATION
<br /> KSIDE SEWER ALTERATION C G ' `v" ) 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 /> ❑ IAM 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
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<br /> OWNER NAME: TENANT BUSINESS AME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET 4 77111 P1
<br /> CITYEv Ef GIT- STATE VD IrC ZIP
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME: Y(` C-5 1-(j(f R. cc) c, V
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<br /> CONTRACTOR ADDRESS: STREET 1✓/l goo /✓
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<br /> CITY 0 /1 STATE I} ZIP k-cA L
<br /> CONTRACTOR PHONE: LI 2 c'6 7 Z't-t.8.i k.. CONTRACTOR EMAIL: k aces `'Zi1Z r C,
<br /> CONTRACTOR LIC.#(REQUIRED): F� U NuJ CITY OF EVERETT BUSINESS LIC.#(REQUIRED):
<br /> PRIMARY CONTACT: 0 OWNER .4 ONTRACTOR 0 OTHER(Please Specify),
<br /> CONTA
<br /> AME: ,� i CONTACT PHONE: e 6,- ,ga-7 - S-o24z
<br /> Cr.. (, cr_x4 • s CONTACT EMAIL: (a,rGV‘ 6 ik,l• S Gr-V G( �G�•• \-(°C�'-
<br /> AGREEMENT::The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title 14 Water andSewer 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./am the owner,or I am
<br /> authorized by the owner of di' ropertyto pelf. '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#
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<br /> Owner/A or ed rent '.niture to (Revised 4/1.5/2019)
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