10121 EVERGREEN WAY BASE FILE 2025-08-05

WA'k .A / SEWER UTILITY AP. LICATION CITY OF EVERETi PERMIT SERVICES E V E R E T T 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 UTILITY APPLICATION INFORMATION I all that ❑ SIDE SEWER REPAIR SIDE SEWER ALTERATION (#leW'g/t"c13C�F8�- 11 NEW SIDE SEWER INSTALLATION ❑ INSTALL BACKWATER VALVE (outside the building) ❑ SIDE SEWER CAP -OFF 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. WATER (check all that apply) ❑ BACKFLOW PREVENTION (Outside) - Specify device type below: ❑RPBA (dom.) ❑DCVA (dom.) ❑DCVA (irr.) ❑DCDA (fire) 4WATER LINE BEHIND METER (repair or alteration) ❑ NEW WATER SERVICE INSTALLATION Specify installation type below., ❑ NEW COMPLETE SERVICE ❑ METER ONLY Specify water service type & size below: ❑ DOMESTIC: ❑314" ❑l" 112" ❑Other: ❑IRRIGATION: 034' ❑l" 112" ❑Other: ❑ FIRE: ❑l" 132" 114" 06" ❑8" ❑Other: ❑ DOMESTIC/FIRE COMBO: ❑l" ❑2" ❑Other: I CONTACT INFORMATION OWNER NAME: ROIC TENANT BUSINESS NAME (If Commercial): Vacant OWNER MAILING ADDRESS: STREET 11250 El Camino Real Suite 200 /� CITY San Diego STATE CA zip 92130 OWNER PHONE:858-255-4920 1OWNER EMAIL: rdoran@rolreit.net CONTRACTOR NAME: Select Contracting CONTRACTOR ADDRESS: sTR,,TPO BOX 1746 cm Bothell STATE WA zip 98041 CONTRACTOR PHONE: 206-419-8871 1CONTRAGTOR EMAIL: Selecteontracting@COmeaSt.net CONTRACTOR LIC. #(REQUIRED): SELECC*83501 ICITY OF EVERETT BUSINESS LIC. #(REQUIRED): �J-7 63 PRIMARY CONTACT: ❑ OWNER ❑ CONTRACTOR OTHER (Please Specify) Architect CONTACT NAME: I CONTACT PHONE:206-369-8881 Scott Harris ICONTACTEMAIL: scott.harris@sdharchitect.Com AGREEMENT: The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title 14 Water and Sewer or such othermles and regulations now existing or which may be established Irom 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 repalm, construction, and nonpayment of charges or for any other reasonable cause. 1 am the owner, or I am authorized by the owner of this property to perform the work for which application is made, and 1 comply with the State Contractors Law 18.27 RCW and 296.200A WAC. City of Everett Official Use Only 1� PERMIT #q 3�C&&Wa4A46 d 6/27/23 U 23 0i� z I OwnGdAuthorized Agent Signature Date (Revised 412112022)