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uri 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: j2-Oc/)Q-4/` Wim' cit2i0
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: XtSFR ❑TOWNHOUSE ODUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑ACCESSORY
<br /> CHANGE OF USE? 0 NO ❑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 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: 1:11" 02" ❑Other:
<br /> SINGLE OWNERSHIP.FILL OUT REVERSE SIDE OF THIS FORM. 0 BACKFLOW PREVENTION(Outside): ❑RPBA ❑DCDA ❑DCVA
<br /> .'„ x 3:. 4 EM3E >34.< f,,1:,;.,,'4 i E#01 a 1.�*A� 0y-, .,.•s'11..:?.a,r ,.. .., ,,. }•. 0s. 011811B
<br /> OWNER NAME: yvi T NANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREETS ,.. ,4'21, =�+'�' �'
<br /> CITY J,.J� V:;\N
<br /> 9 1 STATE `Y 4 ZIP �'$ V�
<br /> OWNER PHON .�'Z& Z'►•t 9'`I Z OWNER EMAIL:
<br /> CONTRACTOR NAME: ,�G.,�{,h�C rtt9r t `� LSA L
<br /> CONTRACTOR ADDRESS: STREET �S 24 �r o-1d-VQ I A
<br /> CITY� frs STATE W I '
<br /> CONTRACTOR PHONE:((kW 2.'M • -- 44CONTRACTOR EMAIL: LA../cast-41÷. w/41"64` '; ; ' •
<br /> CONTRACTOR LIC.#(REQUIRED): Lab4 4t 0 CITY OF EVERETT BUSINES LIC.#(RE,1�Rift, •
<br /> PRIMARY CONTACT:,,.0 OWNER 0 CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: �. trb0tISZ CONTACT PHONE: (4z )
<br /> CONTACT EMAIL: W "vr.4s",v44ZX 0.46.4I'6tr$'1
<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 a•rees,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, struction,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 perfo i • e work for which a, ation 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 /> . t 034--
<br /> Owner/Au gnature Date (Revised 4/15/2019)
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