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,. WATE / 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 l www.everettwa.govipermits
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<br /> PROJECT ADDRESS: � L . � - �, . .
<br /> I,APPLICABLE: 0 OUTSIDE CITY LIMITS O BUILDING AREA , SF 0 LOT#
<br /> BUILDING TYPE: 'MPR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS` ❑COMMERCIAL ❑INDUSTRIAL
<br /> ` CHANGE OF USE? 0 NO 0 YES, FROM TO
<br /> _•- --,-_ 'till 411001.414"-:;":'',111,• , ex �;EE3 `>.. � b . _ , '. d @°YE, �:A rrna :=:- . , , ato :a� A
<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> 'I 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 0 MULTI-FAMILY-#OF UNITS:
<br /> ❑SIDE SEWER RECONNECTION 0 COMMERCIAL
<br /> MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE: (circle desired size)
<br /> ❑I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR 0 DOMESTIC: 3/4", 1", 2", OTHER:
<br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP, 0 IRRIGATION: 3/4", 1", 2", OTHER:
<br /> ❑I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER 0 FIREI 1", 2", 4", 6", F OTHR1
<br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER 0 STIC/FIRE COMBO: 1", 2", OTHER
<br /> SINGLE OWNERSHIP.FILL.OUT REVERSE SIDE OF THIS FORM. 0 BACKFLOW PREVENTION(outside): RPBA DCDA DCVA!,
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<br /> OWNER NAME: jt) krk TENANT NAME ilf.Ealmrtie tti it)f..
<br /> OWNER MAILING ADDRESS: STREET , m I°} {" ......
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<br /> �,: sa4F i dlt+1 OWNER PHONE:
<br /> 4 OWNER EMAIL: 4 r ,+, .. � �� k _._
<br /> CONTRACTOR NAME: t (11C,r) Mi m . y
<br /> CONTRACTOR ADDRESS::. STREET c 11.
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<br /> CONTRACTOR,PHONE .n c CONTRACTOR EMAIL: .- ' 4
<br /> CONTRACTOR LIC.#I(REQUIRE0y t((Z I , (122,Aff& [CITY OF EVERETT BUSINESS LIC."#(REGIUIREC):0 I 'I
<br /> PRIMARY CONTACT: 0 OWNER 1ONTRAM 0 OTHER(Please Specify) ,,
<br /> CONTACT NAME: CONTACT PHONE: �' - 4""
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<br /> CONTACT EMAIL: �ri... � } - ,
<br /> AGREEMENT:The undersigned applicant ag •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 time to time.The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have the right at any
<br /> time,without notice,to shut off or turn on the water supply for repairs,construction,end nonpayment of charges or for any other reasonable cause.I am the owner,or I am
<br /> authorized by the owner of this prbp: to perfomr the work for which application Is made,and/comply with the State Contractors Law 18.27 RCW and 295200A WAC.
<br /> City of Everett Official Use Only
<br /> PERMIT#
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<br /> . . �� U ` L1 1 - 01
<br /> * '' 1 h .• s:`; (Revised 812/2018)
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