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WPWR / SEWER UTILITY Pqr <br />LICATION <br />CITY OF EVERETT PERMIT SERVTES <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 />PROJECT ADDRESS: -::1 T`^ r= ' # <br />IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDING AREA SF IR LOT # <br />BUILDING TYPE: MSFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI -FAMILY-# OF UNITS: ❑COMMERCIAL ❑ACCESSORY <br />CHANGE OF USE? giNO ❑ YES, FROM TO <br />UTILITY `APPIICATION `INFORMATION <br />SEWER (check all that apply) <br />WATER (check all that apply) <br />❑ SIDE SEWER REPAIR <br />-W WATER SERVICE INSTALLATION <br />❑ w <br />❑ SIDE SEWER ALTERATION <br />❑ COMPLETE SERVICE METER ONLY Jol <br />❑ NEW SIDE SEWER INSTALLATION <br />SERVICE / METER USE: <br />❑ INSTALL BACKWATER VALVE (outside the building) <br />❑ SFR <br />❑ SIDE SEWER CAP -OFF <br />❑ MULTI -FAMILY - # OF UNITS: <br />$IDE SEWER RECONNECTION <br />❑ COMMERCIAL <br />WATER SERVICE TYPE / SIZE: (provide calcs to support size choice) <br />-MESTIC: '14" 111" 112" ❑Other: <br />MULTIPLE DOMESTIC WATER SERVICES REQUEST <br />❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR <br />MY MULTI -FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. <br />❑ IRRIGATION: 113/4" El 112" []Other: <br />❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER <br />❑ FIRE: ❑1" ❑2" 114" 116" ❑8" ❑Other <br />SERVICES FOR MY MULTI -FAMILY DEVELOPMENT UNDER <br />❑ DOMESTIC/FIRE COMBO: ❑l" ❑2" ❑Other <br />SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. <br />❑ BACKFLOW PREVENTION (Outside): ❑RPBA ❑DCDA ❑DCVA <br />CONTACT INFORMATION <br />OWNER NAME: cp -Z ' r w 5 <X " TENANT BUSINESS NAME (If Commercial): <br />OWNER MAILING ADDRESS: STREET <br />CITY V STATE ZIP <br />OWNER PHONE:, - < \ ram,, i -I'l -7 l <br />OWNER\\EMAIL: 1_• \ r._, <br />CONTRACTOR NAME: - <br />_ r � <br />CONTRACTOR ADDRESS: STREET v <br />CITY 'J -« STATE ZIP C I <br />CONTRACTOR PHONE: -1 5 <br />CONTRACTOR EMAIL: Z (QO <br />n/ <br />CONTRACTOR LIC. #(REQUIRED): !'TU�.UaxA " r � air �� <br />CITY OF EVERETT BUSINESS LI . #REQUIRED): � <br />PRIMARY CONTACT: ❑ OWNER ❑ CONTRACTOR ELOTHER (Please Specify) �f' <br />CONTACT NAME: <br />CONTACT PHONE: - _ rr <br />���� <br />CONTACT EMAIL: ' ` ;�, ) - ✓��,/� \vU Jul <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. 1 am the owner, or I am <br />authorized by the owner of this prop to perform 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 />U i Z DD� <br />Owner/Abrthorized Agent Signature Date (Revised 411512019) <br />