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171 <br />• <br />WATER / SEWER UTILITY APPLICATION <br />EVERETT <br />WASHINGTON <br />CITY OF EVERETT PERMIT SERVICES <br />3200 CEDAR STREET, EVERETT, WA 98201 <br />(P) 425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits <br />PROJECT SITE INFORMATION <br />PROJECT ADDRESS: 1314 122nd St. SE, Everett, WA 98208 <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? ❑✓ NO ❑✓ YES, FROM septic TO sewer <br />UTILITY APPLICATION INFORMATION <br />SEWER (check all that apply) <br />WATER (check all that apply) <br />❑ SIDE SEWER REPAIR <br />❑ NEW WATER SERVICE INSTALLATION <br />❑ SIDE SEWER ALTERATION <br />❑ COMPLETE SERVICE ❑ METER ONLY <br />❑✓ NEW SIDE SEWER INSTALLATION e (j 2_5j.0Vi3► <br />SERVICE / METER USE: <br />❑ INSTALL BACKWATER VALVE (outside the building) UN "Im <br />❑ SFR <br />❑ SIDE SEWER CAP-OF� l po04�5LiU oo,l.(2b) 1y 55 So; <br />❑ MULTI -FAMILY - # OF UNITS: <br />❑ SIDE SEWER RECONNECTION 'A (Obu.p— <br />❑ COMMERCIAL <br />WATER SERVICE TYPE / SIZE: (provide calcs to support size choice) <br />MULTIPLE DOMESTIC WATER SERVICES REQUEST <br />❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR <br />❑ DOMESTIC: ❑3/4,, Or ❑2" ❑Other : <br />MY MULTI -FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. <br />❑ IRRIGATION: ❑3/4,, ❑v 112" ❑Other : <br />❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER <br />❑ FIRE: ❑l" ❑2" ❑4" ❑6" 08" ❑Other : <br />SERVICES FOR MY MULTI -FAMILY DEVELOPMENT UNDER <br />❑ DOMESTIC/FIRE COMBO: ❑1,, ❑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: Brent and Jenijoy Black TENANT BUSINESS NAME (If Commercial): <br />OWNER MAILING ADDRESS: IIREET1314 122nd St. SE <br />o,Tv Everett STATE WA z,P 98208 <br />OWNER PHONE:425-616-8846 <br />1OWNER EMAIL:happyspy@comcast.net <br />CONTRACTOR NAME:H2FIOW Plumbing <br />CONTRACTOR ADDRESS: STIEET5030 163rd PI SW <br />c,T,. Edmonds STATE WA z,P 98026 <br />CONTRACTOR PHONE:206-247-5477 <br />1CONTRACTOR EMAIL: hbaker1981 @gmall.COm <br />CONTRACTOR LIC. #(REQUIRED):H2FLOP*820MB <br />CITY OF EVERETT BUSINESS LIC. O(REQUIRED. .1111 <br />PRIMARY CONTACT: I] OWNER ❑ CONTRACTOR ❑ OTHER (Please Specify) <br />CONTACT NAME: <br />Jenijoy Black <br />CONTACT PHONE:425-616-8846 ) l� <br />CONTACTEMAIL:happyspy@comcast.net <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. 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 1 comply with the State Contractors Law 18.27 RCW and 296.200A WAC_ <br />Agent Signature <br />4/30/2021 <br />Date <br />City of Everett Official Use Only <br />PERMIT # <br />U "- <br />21 l�) - U) <br />(Revised 1011212018) <br />