620 112TH ST SE SPACE 17 2023-12-29

WATER I SEWER UTILITY APPLICATION CITY OF EVERETT PERMIT SERVICES EVERE i f WASHINGTON SUBMITTAL INSTRUCTIONS: Drop off hard copy paper application & plans to 3200 Cedar Street 2nd Floor Intake Drop Box. CONTACT INFORMATION: (P) 425-257-8810 1(E) PermitServices@_everettwa.gov I (W) everettwa.gov/permits PROVGYT SI ! E INFOMMATION PROJECT ADDRESS: J 2-© 11 �k- �r S t.e- 11 rn e PeF/ v 9e2-p IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF ❑ LOT # BUILDING TYPE: 'NSFR ❑TOWNHOUSE ❑DUPLEX OADU ❑MULTI -FAMILY-# OF UNITS: ©COMMERCIAL OACCESSORY CHANGE OF USE? WNO OYES, FROM TO UTILITY APPLICATION INFORMATION SEWER (check all that apply) WATER (check all that apply) ❑ SIDE SEWER REPAIR ❑ SIDE SEWER ALTERATION ❑ NEW SIDE SEWER INSTALLATION ❑ INSTALL BACKWATER VALVE LoLdside the bamft) SIDE SEWER CAP -OFF 0 SIDE SEWER RECONNECTION 0 BACKFLOW PREVENTION (Outside) - Specifydeviee type below.• ❑RPBA (dote.) ODCVA (door.) ODCVA (irr.) ❑DCDA (fire) 0 WATER LINE BEHIND METER (repair or alteration) 0 NEW WATER SERVICE INSTALLATION Specify installation type below.- 0 NEW COMPLETE SERVICE 0 METER ONLY Specify water service type & size below: 0 DOMESTIC. 03w ❑i" 02" Oother : ❑ IRRIGATION: 03/4" 01" 02" ❑Other : ❑ FIRE: 01" TOZ" 04" 06" 138" 00ther : ❑ DOMESTIC/FIRE COMBO: O 1" 02" 00ther : MULTIPLE DOMESTIC WATER SERVICES REQUEST ❑ 1 AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR MY MULTI -FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ 1 AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER SERVICES FOR MY MULTI -FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. CONTACT INFORMATION OWNERNAME. " TENANT BUSINESS NAME (If Comnwci : OWNER MAILING ADDRESS: STREET T ��^ 4, CITY fg,'_ ! % /f h j A STATE W✓s'I` ZtP OWNER PHONE: a' 5 `-1 tI EMAIL °"S r� -44 ^111 7 L V#j 0DOWNER CONTRACTOR NAME: Kl re✓ �, r_ 1 / -tm � I ` 1 0,0 i� '*' r�Q L CONTRACTOR ADDRESS: STREET 0 _g4 e� 5s Je CRY ,�1-49'�R"Ta '/ STATE tWA ZIP CONTRACTOR PHONE: tg°� 3 Ii I CONTRACTOR EMAIL: Ulf' a' c. r" '' r, v . c tides CONTRACTOR LIC. #(REQUIRED): WPR W �2 02- y IV d CITY OF EVERETT BusiNEss LIc. REQUIRED): PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR 'OTHER (Please Specify) S "'/') Or o 01-e-- CONTACT NAME: // ,,,, Poet wo o c � e d' CONTACT PHONE: 1-1- .S 5,812 610 �Ij CONTACT EMAIL:,, 6j & , t ss n. G ✓- j n 3 0 n" AGREEMENT. The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title 14 Water and Sewer or such other mites and regulations now existing or which may be established from time to time. The applicant further agrees as a condkon precedent to receiving service chat the utilities division shag have the right at any time, without notice, to shut off or tum on the water supply for repairs, construction, and nonpayment of charms or for any other reasonable cause. I am the owner, or I am authorized by the snv_rw of this property to perlbrm the work for which appiication is made, and I comply with the State Contractors taw 18.27 RCW and 296.200A WAC. City of Everett Official Use Only PER # Date (Revised 4:2112022)