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WATER / SEWER UTILITY APPLICATION <br />EVERETT <br />WASHINGTON <br />CITY OF EVERETT PERMIT SERVICES <br />SUBMITTAL INSTRUCTIONS: Drop off hard copy paper application & plans to 3200 Cedar Street 2nd Floor Intake Drop Box. <br />CONTACT INFORMATION: (P) 425.257.8810 1 (E) PermitServices@everettwa.gov I (W) everettwa.gov/permits <br />PROJECT SITE INFORMATION <br />PROJECT ADDRESS: S 14 1 <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 TO <br />UTILITY APPLICATION INFORMATION <br />SEWER (check all that apply) <br />WATER (check all that apply) <br />❑ SIDE SEWER REPAIR <br />je2E SEWER ALTERATION <br />NEW SIDE SEWER INSTALLATION <br />❑ INSTALL BACKWATER VALVE (outside the building) <br />❑ SIDE SEWER CAP -OFF <br />❑ SIDE SEWER RECONNECTION <br />❑ BACKFLOW PREVENTION (Outside) - Specify device type below: <br />❑RPBA (dom.) ❑DCVA (dom.) ❑DCVA (irr.) ❑DCDA (fire) <br />❑ WATER LINE BEHIND METER (repair or alteration) <br />❑ NEW WATER SERVICE INSTALLATION <br />Specify installation type below: <br />❑ NEW COMPLETE SERVICE <br />❑ METER ONLY <br />Specify water service type & size below: <br />❑ DOMESTIC: ❑3/4" 111" 112" ❑Other : <br />IRRIGATION: 133/4" ❑l" 112" ❑Other : <br />❑ FIRE: ❑l" ❑2" ❑4" ❑6" ❑8" ❑Other : <br />❑ DOMESTIC/FIRE COMBO: ❑l" 112" ❑Other <br />MULTIPLE DOMESTIC WATER SERVICES REQUEST <br />❑ 1 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 />CONTACT INFORMATION <br />OWNER NAME: TENANT BUSINESS NAME (If Commercial): <br />OWNER MAILING ADDRESS: STREET ti ' <br />CITY (f STATE ZIP <br />OWNER PHONE: L%,� j' - �� 3G�G <br />OWNER EMAIL: <br />CONTRACTOR NAME: u%e <br />/ <br />CONTRACTOR ADDRESS: STREET bS f / "IA <br />CITY STATE Z'GIP�G'C( <br />CONTRACTOR PHONE: - J � S <br />/+ <br />CONTRACTOR EMAIL: `6111,0 .4 Q I h f r�ht-t7A , 1,-1144 <br />CONTRACTOR LIC. #(REQUIRED): n i-ptcc I q3 6 -6 J <br />CITY OF EVERETT BUSI V ESS LIC. #(REQUIRED): <br />PRIMARY CONTACT: ❑ OWNER CONTRACTOR ❑ OTHER (Please Specify) <br />CONTACT NAME: <br />CV 411 fid <br />CONTACT PHONE: 9,06 - 01-- y 31� <br />CONTACT EMAIL: IH 4/ti,z 0 A" <br />AGREEMENT: The undersigned applicant �grees 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, ire 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 1 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 />/ I / /�4 1U 0 3 z <br />(Revised 81412021) <br />