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III WATER / SEWER UTILITY APPLICATION
<br /> //41/LIIP-4,1,,,,/4 CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT, WA 98201
<br /> (P) 425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits
<br /> PROJECT SITE INFORMATION
<br /> PROJECT ADDRESS: i 7 0 U 3...)—kb T ( c.Al-
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: ❑SFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑ACCESSORY,
<br /> CHANGE OF USE? 0 NO .0 YES, FROM TO
<br /> UTILITY APPLICATION INFORMATION
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> IDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION
<br /> SIDE SEWER ALTERATION ❑COMPLETE SERVICE ❑ METER ONLY
<br /> R 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'INFORMATION
<br /> OWNER NAME: l<i.rt: ; Nn1.-r1-- C::A r C r TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET 19 7 17 `i c 1-1, t,i lz
<br /> CITY4_,..i,;,5 .f-n,," STATE + - ZIP I l4. z i 3
<br /> OWNER PHONE: `t7 3— 5-) :s j 5? j OWNER EMAIL: k Z L0 rye,: A to-o, '«z.
<br /> CONTRACTOR NAME: '"?rA c_ Lj c t 5(..v. (c_►
<br /> CONTRACTOR ADDRESS: STREET Ste) y `"-c,... ,j,- i S
<br /> .c' y
<br /> CITY 1—Y t:'�c.44 STATE \,'./I ZIP C !✓ ,-; I
<br /> CONTRACTOR PHONE: Li 2's-27?— [ sv CONTRACTOR EMAIL: .-1,nyf-;,., I,Ac hr.�lii C w j (e' ) -',c,;f, ,.c;>;-..,
<br /> CONTRACTOR LIC.#(REQUIRED):j,; .ti=Gi...i,d' C S j f;' CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 4'.:1 ?1 `?
<br /> PRIMARY CONTACT: 0 OWNER Er6ONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE:
<br /> ,i,, - s-, i- e(..,tjt,7 CONTACT EMAIL: ;)sn.,'t.•^ Ns 61v:,1l pi,'. r:"%f c,-..:..I . ..i N;:
<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 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 I comply with the State Contractors Law 18.27 RCW and 296.200A WAC.
<br /> City of Everett Official Use Only
<br /> PERMIT#
<br /> / u ,,902- 02_0
<br /> One Authorized Agent Signature Date (Revised 10/12/2018)
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