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A0/411.--- WATER / SEWER UTILITY APPLICATION
<br /> •
<br /> PPLICATIO 1
<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 I www.everettwa.gov/permits
<br /> P�l, .,., ... �� � �_.«�, d�. �iy.,���`���i�a 4440".417,47, e:)
<br /> „PROJECT.ADDRESS: Ulf D 1 Yid 44 d ,«.»
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA, SF 0 LOT# _
<br /> BUILDING TYPE: ❑SFR-DETACHED BSFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS:;. ❑COMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? 0 NO ❑YES, FROM TOI
<br /> SEWERcheck all that apply)j pp fir) WATER(check all that apply)
<br /> IDE 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 /> 0 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 1", 2", 4", 6", L_1 OTH R ❑
<br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER 0 r• r STIC/FIRE COMBO: 1", 2', OTHER:
<br /> SINGLE OWNERSHIP.FILL OUT REVERSE SIDE OF THIS FORM. 0 BACKFLOW PREVENTION(outside): _ RPBA DCDA DCVA
<br /> OWNER ,„,... _„.? .
<br /> NAME. IA) TENANT •NAME fsCtsrintit�3
<br /> ypr
<br /> -OWNER MAILING ADO.' STREET 6 '� " " �"
<br /> CITY_..�„, teres STATE :... ZIPS
<br /> OWNER PHONE: q 5" 5 OWNER EMAIL �,q@ T.A1-10Q,„,,,.:071y)
<br /> 'CONTRACTOR NAME. Q.$0,..11-1f•-.1:11)"1
<br /> 0 1
<br /> C#NT eIkCTOI ADDRESS; STREET _ (pill l .S
<br /> ,. --.- .. CITY. . S _ STATE U 21P� :CON RAcr ft PHONE: r " f.
<br /> � t Vis. CONTRACTOR EMAIL ;AL0. tt t;
<br /> C?NT TOI ,LIC. OUIFii O, 4 ' ".-; CITY OF EVERETT BUSINESS LIC: ouIRED) '5 • *
<br /> PRIMtYCONTACT: 0 OWNER it CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: ......, .-- .
<br /> L,}, ti,,, t .Qc-71 ,--i,
<br /> , .11 t .1 - CONTACT EMAIL a , - IS til € .
<br /> AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title 14 Water and Sewer
<br /> 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,and nonpayment of charges or for any other reasonable cause.I am the owner,or I am
<br /> authorized by the owner of this prop' •a perform the work for which application Is made,and I comply with the State Contractors Law 18.27 RCW and 298.200A WAC.
<br /> City of Everett Official Use Only
<br /> PERMIT#
<br /> Owner/Authoflz:,,, Agent 819 u 5 (Revised 8/2/2018)
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