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,.... ..........73 WATER / SEWER UTILITY APPLICATION
<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 4110101,
<br /> 3200 CEDAR STREET, EVERETT, WA 98201
<br /> (P)425-257-8810 I FAX 425-257-8857 I (E)everetteps@everettwagov I wvvw.everettwagov/permits
<br /> PROJECT SITE INFORMATION
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<br /> PROJECT ADDRESS: 1.1'Li iC) .A104tVC,s,00 ,4/-4,- Lve ce,Ef-,
<br /> IF APPLICABLE: El OUTSIDE CITY LIMIleS ID BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: E.FR OTOWNHOUSE ODUPLEX OADU OMULTI-FAMILY-#OF UNITS: OCOMMERCIAL DACCESSORY 1
<br /> CHANGE OF USE? NNO 0 YES, FROM TO
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<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> '.. SIDE SEWER REPAIR Ell NEW WATER SERVICE INSTALLATION
<br /> 0 SIDE SEWER ALTERATION El COMPLETE SERVICE IJ METER ONLY
<br /> Li NEW SIDE SEWER INSTALLATION SERVICE 1 METER USE:
<br /> 0 INSTALL BACKWATER VALVE(outside the building) LI SFR
<br /> El SIDE SEWER CAP-OFF El MULTI-FAMILY-#OF UNITS:
<br /> LI SIDE SEWER RECONNECTION Li COMMERCIAL
<br /> MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE I SIZE:(provide calcs to support size choice)
<br /> El I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR 0 DOMESTIC: 03/4" Er 2" 00ther:
<br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. 0 IRRIGATION: 03/4" Lii" Lir 00ther:
<br /> El I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER 0 FIRE: 01" 02" 04" 06" 08" 00ther:
<br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER 0 DOMESTIC/FIRE COMBO: 01" 02" 00ther:
<br /> SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. 0 BACKFLOW PREVENTION(Outside): DRPBA DOCDA DDCVA
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<br /> OWNER NAME: ..,,,,r)‘"-; r)( E? W; 1;(ley)% TENANT BUSINESS NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET 11)1 I.5 Pi( ,,,,i rx ofi, 0 r-
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<br /> OWNER PHONE:7,4cl--35S-'/5(1..!^:') 'OWNER EMAIL:
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<br /> CONTRACTOR NAME: .17:tltr-4e. 1-At r-VAli01/1C, tc )4*."+-1/1 \ 1-1..--C,
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<br /> CONTRACTOR ADDRESS: STREET 12-f-r) I Mr)ASir r , .:-, ./... 9v4 57E-3$a
<br /> CITY'. 1e,,KAc3r*--"‘ STATE Ida zip 9m5 7
<br /> CONTRACTOR PHONE:ZCI,..' — 4" CONTRACTOR EMAIL: •7f(N 1C e ' ' I, A -)1()r v )11NA:11-‘2V- 'Pr
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<br /> CONTRACTOR LIC.*REQUIRED): t AMIP)-"\- • o q--) CITY OF EVERETT BUSINESS LIC.CREQuIREDI:
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<br /> PRIMARY CONTACT: El OWNER , 1 ONTRACTOR CI OTHER(Please Specify) ;,:e= - ' I . r,--. Li!
<br /> CONTACT NAME: CONTACT PHONE: 7C, ,,LI 72.:' q
<br /> YY) CONTACT EMAIL: C)i"'CVi ce ilVil4dpititrihifiecheal)
<br /> AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title 14 Water and Sewer or such other ahs and regulaions 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
<br /> 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.lam the owner,or/am
<br /> authorized by the owner of this property to perform the worn 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
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<br /> 1-;&ii 7 PERMIT#
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<br /> N•0411001/Authyri• • ,/Signature (Revised 10/12/2018)
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