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477 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 I www.everettwa.gov/permits <br /> p PROJECT SITE INFORMATION <br /> ,L PROJECT ADDRESS: 27 0? .o INct.4 tj r <br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# <br /> BUILDING TYPE: $SFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL DACCESSORY <br /> CHANGE OF USE? KNO 0 YES, FROM TO <br /> UTILITY APPLICATION INFORMATION <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 ❑MULTI-FAMILY-#OF UNITS: <br /> ❑SIDE SEWER RECONNECTION 0 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" ❑I" 02" ❑Other: <br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. 0 IRRIGATION: 03/4" ❑I" 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: 01" 02" ❑Other: <br /> SINGLE OWNERSHIP.FILL OUT REVERSE SIDE OF THIS FORM. 0 BACKFLOW PREVENTION(Outside): ❑RPBA ❑DCDA ❑DCVA <br /> n CONTACT INFORMATION <br /> OWNER NAME: -S fq,rv` - I"�Q�C G!'..r" En zTEFIANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET g....70 9(�.�44 J YIIQ Na Jr <br /> CITY E�/.,Q(/'„e..(,' STATE 00/4" ZIP ?e ao <br /> OWNER PHONE: OWNER EMAIL: «I <br /> CONTRACTOR NAME: <br /> CONTRACTOR ADDRESS: STREET <br /> CITY STATE ZIP <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED): <br /> PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR I, .OTHER(Please Specify) Fa y`h-' " <br /> CONTACT NAME: CONTACT PHONE: 360./ j1 6 0 V <br /> - o2 0 1 -//�.27 ! /7 <br /> teLrp - CONTACT EMAIL: S E 1 `4 A) ' .&1 I ' CoYYt, <br /> AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title 14 Wafer 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 I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> PERMIT# <br /> /°///R, tal 10 o 32 <br /> Owner/Authorized Agent Signature / Date (Revised 10/12/2018) <br />