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11 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 <br /> / PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: 2 C 0 6 1/ ! C rode- f L' e/I Z- ° / <br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# <br /> BUILDING TYPE: IBFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL DACCESSORY <br /> CHANGE OF USE? Lt"NO 0 YES, FROM TO <br /> UTILITY APPLICATION INFORMATION <br /> SEWER(check all that apply) WATER(check all that apply) <br /> ❑SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION <br /> IE 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 caics to support size choice) <br /> ❑I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR 0 DOMESTIC: 03/4" Di" 02" ❑Other: <br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑IRRIGATION: 03/4" ❑1" 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: <br /> °/7/267 v"/f/r/ .r° TENANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET 2 0 Com'- £ 1 "C tVf Z�/fX/-1-7" g J� <br /> CITY STATE ZIP (��-'r/ <br /> OWNER PHONE: V 2 5 2 `3/'7 "j OWNER EMAIL: C.41 7GyL63� �J <br /> - <br /> CONTRACTOR NAME: 4//i 1 4 �/G't/7,Pi(jt�12 E ,O� J�a / <br /> CONTRACTOR ADDRESS: STREET /2 ,3/. 5y � ^ �� <br /> ' `� CITY STATE(- i/, p ZIP 961:'26›5 <br /> CONTRACTOR PHONE: I7'2s' 25 - /2/2 CONTRACTOR EMAIL: 6'e„--?- ( 4/ �PcIG' G'vY-e� /26t, ., cam, <br /> CONTRACTOR LIC.#(REQUIRED): A LL /L.�D-6-/Zx CITY OF EVERETT BUSINESS LIC.#(REQUIRED): to(5 <br /> PRIMARY CONTACT: .WNER E CONTRACTOR 0 OTHER(Please Specify (�r� <br /> CONTACT NAME:/�-, r CONTACT PHONE: 4/Z,..5 2.6 c' -7 /� -7Ll� <br /> PrL /c°/? 'C 7 ✓! CONTACT EMAIL: /-" � Com !//���/�(�a� �47 <br /> AGREEMENT.:The undersigned applicant agrees to com y with all provisions of the Everett Municipal Code Title 14 Water and Sewer or such other rules and re, lations now <br /> existing or which maybe established from time to time. he 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 tur. . the water supply for repairs,construction,and nonpayment of charges or for any other reasonable cause.I am the owner,or lam <br /> authorized by the owner of this prope '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 /> 4011111b. PERMIT# <br /> 11/0 u Ft Oq "— Ckcl <br /> /� <br /> Owner/Authorized Agent Signature Date (Revised 10/12/2018) <br />