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WATER / SEWER UTILITY APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> EVERETT 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: 2 2 3° L<,,,.,k,r d ,d
<br /> IF APPLICABLE: ❑OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: iii.SFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑ACCESSORY
<br /> CHANGE OF USE? -*NO ❑YES, FROM TO
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<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> 14 SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION
<br /> ❑SIDE SEWER ALTERATION 0 COMPLETE SERVICE ❑ METER ONLY
<br /> ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE:
<br /> ❑ INSTALL BACKWATER VALVE(outside the building) ❑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. ❑ 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 ❑ DOMESTIC/FIRE COMBO: ❑I" 02" ❑Other:
<br /> SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. CI BACKFLOW PREVENTION(Outside): ❑RPBA ❑DCDA ❑DCVA
<br /> M 3 ,.`�..t xsf' t'YG `"1£. t/ #NW:**S* t'� �x .,` rr 4 o> R M
<br /> OWNER NAME: u. �� )e/S� TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET
<br /> CITY STATE ZIP
<br /> OWNER PHONE: 20 6-2 ctd - 3y/ OWNER EMAIL:
<br /> CONTRACTOR NAME: tir,6(.' /G,1+
<br /> '
<br /> CONTRACTOR ADDRESS: STREET 2 nS /541' � p CITY 55:-1/a GJ
<br /> 7
<br /> .t, I� STATE f ZIP (�(
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<br /> CONTRACTOR PHONE:2o6'"2Sn-j 27a CONTRACTOR EMAIL: C Io,,�Q,c�.,e �* �,-, t,/ Ad,co....Gv
<br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED):
<br /> PRIMARY CONTACT: 0 OWNER 7/CONTRACTOR ❑OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE:0 2 S 3- p 8-G f t V /
<br /> G4, /'l i��`rr� CONTACT EMAIL: C n,s��yue f� ��G o/ -ec�h ear-
<br /> AGREEMENT::The undersighed 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 pelf the work for which application is made,and l comply with the State Contractors Law 18.27 RCW and 296.200A WAC.
<br /> City of Everett Official Use Only
<br /> PERMIT#
<br /> 20
<br /> E00 .--00t4
<br /> Owner/Authorized Agent Signature Date/ (Revised 4/15/2019)
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