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Alggit* 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 M www.everettwa.gov/permits
<br /> 120 Aiest asm'n( de
<br /> PROJECT ADDRESS: cf 9
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: ❑SFR-DETACHED FR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL C(INDUSTRIAL
<br /> CHANGE OF USE? 0 NO 0 YES, FROM, ;TO
<br /> SEWER(.check all that apply) WATER(check all that apply) .
<br /> SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION
<br /> ❑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 /> 4 MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE I SIZE:(circle desired size)
<br /> ❑I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR 0 DOMESTIC: 3/4", 1", 2", OTHER:
<br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. 0 IRRIGATION: 3/4", 1", 2", OTHER:.
<br /> ❑I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER 0 FI 1", 2", 4", 6", Imo, OTHI 1 ❑
<br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER 0 _STIC/FIRE COMBO: 1", e OTHER:
<br /> SINGLE OWNERSHIP.FILL OUT REVERSE SIDE OF THIS FORM. 0 BACKFLOW PREVENTION(outside): RPBA DCDA DCVA'.
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<br /> OWNER NAME: U' ., TENANT NAME,If CornTerclat}:,
<br /> OWNER MAILING ADDRESS: STREET c"c
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<br /> cr, g .,AF.1'".� ., ... 2 044
<br /> STATE 4 ZIP 93 ,!.
<br /> OWNER PHONE: , Us55 OWNER EMAIL i 12 @` „v' cp!
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<br /> CONTRACTOR NAME: 0'9 1sj ti n C, ,
<br /> CONTRACTOR ADDRESS: STREET . 0 . •c
<br /> CnY (9f it I STATE 21R
<br /> CONTRACTOR PHONE: 9 o CONTRACTOR EMAIL iv I, sdi`'' , to1 is 0€46 t' 2* Atisjii
<br /> CONTRACTOR.LiC.;#( EQUIREDI: i za' CITY OF EVERETT BUSINESS LIC.#(t EQUIRE3)O3
<br /> PRIMARY CONTACT: 0 OWNER �• CONTRACTOR 0 OTHER(Please Specify)
<br /> 'CONTACT NAME: CONTACT PtIONE: 20(40 Oh
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<br /> ...: CONTACT EMAIL: cbar(cn4,•ni ate itierl, 0. rnr a)oterseate
<br /> AGREEMENT:The undersigned applicant agrees to 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. "`.applicant further agrees,as a condition precedent to receiving service that the utilities division shall have the right at any
<br /> 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!am
<br /> (Oho .< K .the owner of this property to perform .: :;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 /> PERMI
<br /> 9 1 u 1S�9 - 023
<br /> ,,4
<br /> Owner/Authorized Age;t Signature Date (Revised 8/2/2018)
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