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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)everetteps@everettwa.gov I https://everettwa.gov/permits
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<br /> PROJECT ADDRESS: 22- fedfri,Tivi. EveRC'iU
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: PLSFR ❑TOWN HOUSE ❑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 /> igSIDE 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 ❑.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 /> CONTACT INFORMATION
<br /> OWNER NAME: ] W1 401//9_,2_ TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET
<br /> CITY STATE ZIP
<br /> OWNER PHONE: OWNER EMAIL: & ., .4 $
<br /> CONTRACTOR NAME: l ltI K.v A-1,1411 dike
<br /> CONTRACTOR ADDRESS: STREET 4' Cp rrR4( ,t
<br /> CITY kern' STATE ZIP ggo82
<br /> CONTRACTOR PHONE: We).-"1-6C-6/0 CONTRACTOR EMAIL: AHVPROA-1 4BiA§/NCO eiyA-/L, COM
<br /> CONTRACTOR LIC.#fREQUIRED): ,PRaJ/y# CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 53'7;
<br /> PRIMARY CONTACT: 0 OWNER J2ifCONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: ' spivi CONTACT PHONE: 26 ,�..-O/0c
<br /> CONTACT EMAIL: J) /A/pkOi B/A*WC,(49"/"194/ 651/1.1
<br /> AGREEMENT'The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title 14 Water and Sewer or such other tbi6s 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.1 am the owner,or I am
<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 /> City of Everett Official Use Only
<br /> PERMIT#
<br /> oe7 td2q Zo/ U 101. 0 (e 0 5t
<br /> Owne Author! ed Agent Signature
<br /> Dat (Revised 4/1.5/2019)
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