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WAtR / SEWER UTILITY A'LICATION
<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 1 (E) everetteps@everettwa.gov I https://everettwa.gov/permits
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<br /> PROJECT ADDRESS: (Z 02 g .f( 12r. 5
<br /> IF APPLICABLE: 0 OUTSIDE CITY
<br /> LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: kirSFR ❑TOWNHOUSE 0 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 /> ❑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 ❑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. BACKFLOW PREVENTION(Outside): ❑RPBA ❑DCDA `tIDCVA
<br /> OWNER NAME: Ju‘4„ 6 .1 — to TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET /Z OL g (4/44 jr •
<br /> 11
<br /> CITY 6^vert, STATE ZIP ! 0 Z-08.
<br /> OWNER PHONE: 4/ZS- Z"' 5-763 OWNER EMAIL .l✓' n--c4 1t
<br /> CONTRACTOR NAME: Owif,
<br /> CONTRACTOR ADDRESS: STREET
<br /> CITY STATE ZIP
<br /> CONTRACTOR PHONE: CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED):
<br /> PRIMARY CONTACT: DOWNER 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 maybe 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 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 /> Atie
<br /> � �( U ( O� - 00
<br /> Owne/•uthor ed Agent Sig ture Date (Revised 4/1.5/2019)
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