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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)everefteps@everettwa.gov I https://everettwa.gov/permits
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<br /> PROJECT ADDRESS: 77 �r
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<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: etSFR ❑TOWNHOUSE ODUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑ACCESSORY
<br /> CHANGE OF USE? 0 NO 0 YES, FROM TO
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<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> ASIDE 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 ❑ MULTI-FAMILY-#OF UNITS:
<br /> ❑SIDE SEWER RECONNECTION El 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 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 /> OWNER NAME: TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET
<br /> CITY STATE ZIP
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME: f 1tes folio'` C ot%\ST Cx\o
<br /> CONTRACTOR ADDRESS: I 162O2$ t3eitpm(sea. goa4QJ A/
<br /> CITY garlic 11 STATE Wt Yf ZIP
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<br /> CONTRACTOR PHONE: 206'O 7a 48'11 CONTRACTOR EMAIL: ti rn ' V QtI$ NW+ •• iii V f
<br /> CONTRACTOR LIC.#(REQUIRED): N,W CITY OF EVERETT BUSINESS LIC.#(REQUIRED): G
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<br /> PRIMARY CONTACT: 0 OWNER ►- ONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: g(96 r a2.7 gatk3
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<br /> AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title 14 Water7d Sewer or such othdr 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 shu off or tum on the water supply for repairs,construction,and nonpayment of charges or for any other reasonable cause.I am the owner,or l am
<br /> authorized by the owner of is perty 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#gtotlr Oa
<br /> 7
<br /> Owne uthorize e S ture D e (Revised 4/15/2019)
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