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WATER / SEWER UTILITY APPLICATION CITY OF EVERETT PERMIT SERVICES EVERETT SUBMITTAL INSTRUCTIONS: Drop off hard copy paper application&plans to 3200 Cedar Street 2nd Floor Intake Drop Box. WASHINGTON CONTACT INFORMATION: (P)425-257-8810 1(E)PermitServices@everettwa.gov I(W)everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: ;� /f�W I �G� '.1 IF APPLICABLE: ❑ OUTSIDE CITY LIMITS BUILDING AREA JSG SF CI LOT# �o Z BUILDING TYPE: VISFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑ACCESSORY CHANGE OF USE? NO ❑YES, FROM TO UTILITY APPLICATION INFORMATION SEWER (check all that apply) WATER (check all that apply) ❑ SIDE SEWER REPAIR ❑ BACKFLOW PREVENTION (Outside)-Specify device type below: SIDE SEWER ALTERATION ❑RPBA(dour.) ❑DCVA(dom.) ❑DCVA(ir ❑DCDA(fire) EW SIDE SEWER INSTALLATION ❑WATER LINE BEHIND METER(repair or eration) ❑ TALL BACKWATER VALVE (outside the building) C7 NEW WAInsta ERVICE INSTAL ION ❑ SIDE SEWER CAP-OFF Specify tion typ elow: �L I�Cr✓ SID E�GONNEeM ❑ NEW COMPL ERVICE MULTIPLE DOMESTIC WATER SERVICES REQUEST ❑ METER 9 LY � rfRE ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR Specify water service type&siz elow: MY MULTI-FAMILY DEVELOPME,N�YN ,DER SINGLE OWNERSHIP. U60MESTIC: ❑3/4" 01" ❑2" ❑Other El AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑ IRRIGATION: ❑3/4" ❑1" ❑ ❑Other: SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER El FIRE: ❑1" ❑2" ❑4" ❑6" ❑8" ther: SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. I DOMESTIC/FIRE COMBO: 1" 02" ❑Other: CONTACT INFORMATION OWNER NAME: ,] f� '6 c-.V F, L o1^ i c TENANT BUSINESS NAME If Commercial): OWNER MAILING ADDRESS: STREET G:t- / J.7 "lt CITY F--I STATE �. I WA ZIP OWNER PHONE: Z Z OWNER EMAIL: S �a��l (zz !?tis/J CU,i CONTRACTOR NAME: T-'i j .P_ 141 E. S Z L C CONTRACTOR ADDRESS: STREET '7b'Zu � C- Al CITY L kQJ S I C ✓ CTI S STATE ZIP z CONTRACTOR PHONE: "._�- S7o -/OZZ ` CONTRACTOR EMAIL: R� (� �c < /1�t '/��"/�Q 1 CONTRACTOR LIC.#(REQUIRED): �.� % L,f �:' r CITY OF EVERETT BUSINESS LIC.#(REQUIRL ,:.�L=� YJd PRIMARY CONTACT: ElOWNER ❑ CONTRACTOR ❑ OTHER(Please Specify) C,/v '� 5>,f P/- r'L•. CONTACT NAME: CONTACT PHONE: i/zS,_7-7-3 7 r CONTACT EMAIL: r` E , Q AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title 14 Water a d Sewe r such other rules and regulations now 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 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./am the owner,or I am 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. City of Everett Official Use Only PERMIT# Cc 2 G 20--3 U _-� I, Owner/Auth6dzl Agent Signature Date (Revised 412112022)