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WATER / SEWER UTILITY APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT, WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857 1 (E)everetteps@everettwa.gov I www.everettwa.gov/permits
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<br /> PROJECT ADDRESS: .Z 3'�,Z. e aNt-1t— ,4s'-C_
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: '12 FR ❑TOWNHOUSE ❑DUPLEX ❑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 /> 6 7SIDE 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" ❑1" 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 /> ,GON"P,�11�"i" INFtiR#I�A"i�'�ON
<br /> OWNER NAME: em . A;V"� TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET
<br /> u CITY STATE ZIP
<br /> OWNER PHONE: 925-3$1-T7U 1 S OWNER EMAIL: bt 6 (' -w 'kl • (t
<br /> CONTRACTOR NAME: rY1t k- PI(km.
<br /> CONTRACTOR ADDRESS: STREET 22Z(q (9 71 tee.. /� /�
<br /> CITY V J STATE ZIP ar 20
<br /> CONTRACTOR PHONE: '2_06-'77Y--7.s 8 CONTRACTOR EMAIL: /14 re Onyt:k es ko/ukk.4pyeel k 1/'At✓► •C°vv`"
<br /> CONTRACTOR LIC.#(REQUIRED): ►' ` vj e S IP( q c(O CITY OF EVERETT BUSINESS LIC.#(REQUIRED): OSZZ7
<br /> PRIMARY CONTACT: ❑OWNER CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE:26 -7 914 r 7�
<br /> 12 h/\ � CONTACT EMAIL: Afar k. W %.A.) yvvo,110 Cam
<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 lam
<br /> authorized by the owner f 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 /> ' N ' PERMIT City of Everett Official Use Only
<br /> /It
<br /> 6/( / / u l o DC7 o
<br /> 0 er/Authorized A.• Signature Date (Revised 10/12/2018)
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