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<br /> ,',,,„� WATER 1 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'I WWv everettwa.gov/permits
<br /> ' ,:-.),'''',IP.,,,::" .? . ECT T'E INFORMATIOI+Il ' j, ; ';
<br /> PROJECT ADDRESS: 1$0 Wish(• Oc`a L7 ,
<br /> IF APPLICABLE: 0 OUTSIDE CITY'LIMITS 0 BUILDING AREA SF D'LOT#
<br /> BUILDING TYPE: E34F OTOWNHOUSE DDUPLEX DADU DN1ULTl-FAMILY-#OF•UN.ITS; CICOMMERCIAL DACCESSORY'
<br /> CHANGE OF USE? D NO D YES, FROM TO
<br /> N NIA
<br /> _., �. . _..,..� IUTi4I'I�1f L
<br /> ARp ,d �`I"Mt'� .,. I�1.�` TIf3N •., .. .. ...y_. ,.... ,.,._,..,�. .,. ' X..
<br /> SEWER(check all,that apply) WATER(check all that apply)
<br /> SIDE SEWER REPAIR LJ NEW WATER SERVICE:INSTALLATION
<br /> El SII E.SEWER ALTERATION 0 COMPLETE SERVICE El METER ONLY.
<br /> CI NEW SIDE SEWER INSTALLATION SERVICE t.METER USE:
<br /> 0 INSTALL BACKWATER VALVE(outside the building) 0 SFR
<br /> SIDE SEWER GAP OFF 0 MULTI-FAMILY-#OF„UNITS:
<br /> SIDE SEWER;RECONNECTION L. COMMERCIAL
<br /> MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE t SIZE:(provide calm to support size choice)
<br /> D I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR 0 DOMESTIC: d3t4” Dv' 02” DOther:
<br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑IRRIGATION; 03/4" 01 02" DOther:
<br /> L❑I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER D FIRE: 01" 02" 04" Do" 08" Dottier:
<br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER 0 DOMESTIC/FIRE COMBO:. D1 DT ( Other: •
<br /> SINGLE OWNERSHIP,FILL OUT REVERSE SIDE OF THIS FORM. D BACKFLOW PREVENTION(Outside): ORPBA DDCDA DDCVA.
<br /> CONTACT INFORNIAT ON
<br /> OWNER-NAME: ttr)Cl TENANT BUSINESS NAME(If Commercial): ,
<br /> OWNER MAILING ADDRESS: STREET (c (s ''J1 tti,( �' L>1.--1 U''. .
<br /> crh: EVel-setim STATE VW ZIP I 3
<br /> OWNER PHONE: la
<br /> . r * t g OWNER EMAIL:� ' 7C #f' i +Il. .4 f • #
<br /> CONTRACTOR NAM : O,Si "1 ?nil, fir
<br /> CONTRACTOR ADDR STREET t {
<br /> E crrY (sp t'C.� sure bc,,3t ,zJP Rat)
<br /> CONTRACTOR PHONE;Oe�� £. ( (CONTRACTOR EMAIL: .^' r c� �, Torr ,Q.e . 'T.
<br /> CONTRACTOR LIC #(REQUIRED) � y
<br /> ��I1t IGtTY OF EVERETT BUSINESS LIC,#(REQUIRED) +(,� �' Dark)
<br /> PRIMARY CONTACT. D OWNER CONTRACTOR 0 OTHER(Please Specify) /,, . �r -y t
<br /> CO ACT NAME: CONTACT PHONE: C ? ( j C --1 f 7
<br /> t -av- er le LA ii ' '' CONTACT EMAIL: ��. 1 / !B I ', S t� X11/
<br /> AGREEMENT The undersigned•applicant agrees to GM with all provisions of the Everett Municipal Code.Title 14 Water and Sewer or,such otherm/es 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 theutilities 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.tam the owner,or t am
<br /> authorize. , the owner of this proporty to perform the,worit for which application is made,and i comply with the Slats Corttiactors Law 18.2T I1CW and 2961,200A WAC,
<br /> i Cit.of aver-eft Official Use Only
<br /> PERMIT
<br /> 7 / U \670 - 01
<br /> • -. Authorized Agent=ignatur4 Date (Revised 10/1212018)
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