Laserfiche WebLink
WAOER / SEWER UTILITY AgPLICATION <br />CITY OF EVERETT PERMIT SERVICES <br />EVERETT <br />WASHINGTON <br />3200 CEDAR STREET, EVERETT, WA 98201 <br />(P) 425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I https://everettwa.gov/permits <br />PROJECT SITE INFORMATION <br />_ <br />PROJECT ADDRESS: O �2, ;soy s —�e� to <br />IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT # <br />BUILDING TYPE: ❑SFR ❑TOWNHOUSE ❑DUPLEX ❑ADU []MULTI -FAMILY-# OF UNITS: COMMERCIAL ❑ACCESSORY <br />CHANGE OF USE? ONO ❑ YES, FROM TO <br />UTILITY; APPLICATION INFORMATION <br />SEWER (check all that apply) <br />WATER (check all that apply) <br />❑ SIDE SEWER REPAIR <br />❑ SIDE SEWER ALTERATION <br />NEW SIDE SEWER INSTALLATION <br />❑ INSTALL BACKWATER VALVE (outside the building) <br />❑ SIDE SEWER CAP -OFF <br />SIDE SEWER RECONNECTION <br />❑ NEW WATER SERVICE INSTALLATION <br />❑ COMPLETE SERVICE ❑ METER ONLY <br />SERVICE / METER USE: <br />❑ SFR <br />❑ MULTI -FAMILY - # OF UNITS: <br />❑ COMMERCIAL <br />WATER SERVICE TYPE / SIZE: (provide calcs to support size choice) <br />❑ DOMESTIC: 113/4" ❑l" ❑2" ❑Other : <br />❑ IRRIGATION: 113/4,, El 112" ❑Other <br />❑ FIRE: ❑l" 112" ❑4" ❑6" 118" ❑Other <br />❑ DOMESTIC/FIRE COMBO: Or ❑2" ❑Other <br />❑ BACKFLOW PREVENTION (Outside): ❑RPBA ❑DCDA ❑DCVA <br />MULTIPLE DOMESTIC WATER SERVICES REQUEST <br />❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR <br />MY MULTI -FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. <br />❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER <br />SERVICES FOR MY MULTI -FAMILY DEVELOPMENT UNDER <br />SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. <br />GJ <br />�h CONTACT INFORMATION <br />OWNER NAME: cra^ <br />F TENANT BUSINESS NAME (If Commercial): e <br />OWNER MAILING ADDRESS: STREET (' <br />CITY ✓No STATE ZIP IOU S <br />OWNER PHONE: 3 cl 15 <br />OWNER EMAIL: OL cL �(' �fa VIA, <br />CONTRACTOR NAME: �� C <br />C0A �(� Q � UhM lO.hC' <br />CONTRACTOR ADDRESS: STREET P <br />CITY mcc,�71 STATE ZIP <br />CONTRACTOR PHONE:`] &ta2 <br />1CONTRACTOR EMAIL: U,GLO'LoN <br />; n C I%AAAl EV <br />CONTRACTOR LIC. #(REQUIRED): (,,, O I -A ft_ G I O2, " <br />CITY OF EVERETT BUSINESS LIC. #(REQUIRED): <br />PRIMARY CONTACT: ❑ OWNER CONTRACTOR ❑ OTHER (Please Specify) <br />CONTACT NAME: <br />CONTACT PHONE: S 'J� 3- �� r <br />l <br />CONTACT EMAIL: �j S C� ✓� [� C IP/V\ X1 LO . G 0 vh <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 turn on the water supply for repairs, construction, and nonpayment of charges or for any other reasonable cause. l 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 />1013l <br />Agent Signature Date <br />City of Everett Official Use Only <br />PERMIT # <br />U D -- ol <br />(Revised 411512019) <br />