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WATER / 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 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits
<br /> PROJECT ADDRESS: .. • ill 0'.Ai , fr
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING ARE. SF 0 LOT#
<br /> Bull: O TYPE: �FR-DETACHED ❑,:SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: OCOMMERCIAL ❑INDUSTRIAL
<br /> CHANGE OF USE? 0 NO ❑YES, FROM• TO - ,.
<br /> MP NVe,'4, ° ,r < y? O N '', an „ * s
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<br /> SEWER ichec(all that apply) WATER(check all that apply)
<br /> FIDE SEWER REPAIR ❑NEW WATER SERVICE INSTALLATION
<br /> ❑SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY
<br /> ❑NEW SIDE SEWER INSTALLATION SERVICE I 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 I SIZE:(circle desired size)
<br /> ❑I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR 0 DOMESTIC: 3/4", 1", 2", OTHER:
<br /> .
<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", $-,-, 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 /> CANNER NAME., itcri cZobirtsori TENANT.NAME IN Commercial):
<br /> OWNER:MAILING ADDRESS: STREET,314-3.?.; Lory-ibturiel- Ave.
<br /> ZIP ' '
<br /> OWNtR PHONE: , ., fp__ -p 7OWNER EMAIL..,. c'Im r '
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<br /> CONTRACTOR NAME ScriStliel 11X Ar. Pt h' e it ' .g
<br /> CONTRACTOR ADDRESS: STREET S 1t1 '` s ,
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<br /> CflY.' !t1 STATE t.oAt
<br /> CONTRACTOR PHONE: t :.` ` .: 'CONTRACTOR EMAIL: .,< "'r int . .
<br /> CONTRACTOR LIC.#(REG'DIRE. ): t# ' /v6ir- 'CITY OF EVERETT BUSINESS LIC.wRectutREF g 0
<br /> PRIMARY.CONTACT: 0 OWNER !r 4NTRACTOR 0 OTHER(Please Specify) --
<br /> CONTACT NAME: CONTACT PHONE:
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<br /> CONTACT EMAIL; y a ;� . I r ” , -
<br /> AGREEMENT.*The undersigned applicant agreesaly?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,and nonpayment of charges or for any other reasonable cause.I am the owner,or I am
<br /> authorized by the owner of this property to perform the work for which application is made,and I comply with the State Contractors Law 18.27 RCW end 296.200A WAC.
<br /> City of Everett Official Use Only
<br /> I PERMIT#
<br /> A t A .4 ..ik.� + U V $CPOld
<br /> *wile Authorized/Vas Sistrat '' ADate "" (Revised 8/2/2018)
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