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111 WATER / SEWER UTILITY APPLICATION
<br /> `i CITY OF EVERETT PERMIT SERVICES
<br /> EVERETT 3200 CEDAR STREET, EVERETT, WA 98201
<br /> WASHINGTON (P)425-257-8810 I FAX 425-257-8857 1 (E)everetteps@everettwa.gov 1 https://everettwa.gov/permits
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<br /> PROJECT ADDRESS: 1c2 I g t,.i n;e..,-- A'.n_ q",,,,..„4--1 ,,,n. 9 •4,1
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: ❑SFR ❑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 /> 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 ❑.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 a ^ , . ? . g
<br /> OWNER NAME: TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET g -9 1 52.....4...,- if
<br /> a _ /
<br /> CITY �YY4.,,,o {/y STATE ZIP 9 jf al
<br /> OWNER PHONE: OWNER EMAIL:
<br /> CONTRACTOR NAME: Z.1,r,,,D-kcc � .5 -- J Sot . ij e NI*`.) wA.j .1...-r--
<br /> CONTRACTOR ADDRESS: STREET 1-/C)01, e,..,r I s 4 A
<br /> CITY .5/1,1 ,s -- ..__ •TE 4 ! ZIP 9 i, 0
<br /> CONTRACTOR PHONE: f'g 70..,7 46 CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): ' /"'KI (!J,.- CITY OF EVERETT BUSINESS LIC.#(REQUI D): 4 'moi(Q
<br /> PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: k.k.225 g4,5Z4 1
<br /> Cp_____so j_____
<br /> lite,Kv_ 3 tv1,1C\ CONTACT EMAIL—f'_ fl _ Pb` tel(Qt� VR 0 Z t
<br /> AGREEMENT The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title 14 Water and Sewer or suc of anolthatilaw,C
<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 all have the righ 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 [CA()Co Cap
<br /> 0 -41'7orize.Agent Signature Date (Revised 4/1.5/2019)
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