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11)11 "111P'. 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 I (E)everetteps@everettwa.gov I www.everettwa.gov/permits
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<br /> PROJECT ADDRESS: U0/ Irefn se, /4t,p 1l 49V PA/ O1 1,a.tel/
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: ❑SFR ❑TOWNHOUSE 0 DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: OI,COMMERCIAL ❑ACCESSORY,
<br /> CHANGE OF USE? la 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 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" 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 OFTHISFORM.10 BACKFLOW` PREVENTION(Outside): ❑RPBA ❑DCDA ❑DCVA
<br /> S l L Y a k S �. t09.II * II'I 'P.I I IF * ��$y
<br /> 5 S T-c r
<br /> OWNER NAME: Snoe.n — tVGC. TENANT NAME(If Commercial): t.fre,-e,/7 Cir �, �.'h e '//e,e
<br /> OWNER MAILING ADDRESS: STREET
<br /> CITY STATE ZIP
<br /> OWNER PHONE: LS- J 0 ♦ - t 4 S 3 OWNER EMAIL:
<br /> CONTRACTOR NAME: -;• r'- c,i 7kb)
<br /> CONTRACTOR ADDRESS: STREET 2 p/5 J /S 4 S T 1l hp i�/d<�
<br /> CITYl/ S ew f STATE Wed ZIP y
<br /> CONTRACTOR PHONE:�(a-i. ' -5.7t' CONTRACTOR EMAIL:
<br /> CONTRACTOR LIC.#(REQUIRED): /ma,r60/ CITY OF EVERETT BUSINESS LIC.#(REQUIRED):
<br /> PRIMARY CONTACT: ❑OWNER FI CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: 2 53-S o s` ,1-6
<br /> Ave-! /gat-2 ' 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 /> Owner/Authorized Agent Signature Date (Revise 10/12/2018)
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