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WATER / SEWER UTILITY APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> EVERETT
<br /> 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: 901 Gm„,, � -}-
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: ❑SFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COM MERCIAL ❑ACCESSORY
<br /> CHANGE OF USE? 0 NO ❑YES, FROM TO
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<br /> ��3 ��.Na„�?,-fsffi�.� ^�.�”.5... a���. ...�at
<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 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 /> INFORMATIO
<br /> OWNER NAME: cy r,vves,„64L TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET rac)lCryz.,A 14,4
<br /> CITY F„,,,.„-c4-3- STATE ZIP 95,024//
<br /> OWNER PHONE: JOWNER EMAIL:
<br /> 11. CONTRACTOR NAME: //I/t jjr5 / 5, V
<br /> A. S-C.+4.cf- !)nZ;(4-ill rr( fa,`�`} Cu.
<br /> CONTRACTOR ADDRESS: STREET //()2,_ �cw..,\ S-)-
<br /> CITY JiNg.4.4•-+s si-
<br /> STATE �� ZIP 912/A.)
<br /> CONTRACTOR PHONE: CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): ''`ZT/►rTTPSt/OCL CITY OF EVERETT BUSINESS LIC.#(REQUIRED)crei •
<br /> PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE:
<br /> CONTACT EMAIL:
<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 tum 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 /> O er/Authorized Agent Signature Date (Revised 4/15/2019)
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