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WATER / SEWER
<br /> Imo-- UTILITY APPLICATION
<br /> Nimilg - 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 ( www.everettwa.gov/permits
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<br /> PROJECT ADDRESS: 0 3 2 il,y/ Ave
<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT#
<br /> BUILDING TYPE: SFR ❑TOWNHOUSE ['DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑ACCESSORY;
<br /> CHANGE OF USE? 171 NO ,0 YES, FROM TO
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<br /> SEWER(check all that apply) WATER(check all that apply)
<br /> Tgt 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: (provide calcs to support size choice)
<br /> ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR 0 DOMESTIC: 03/4” ❑i" 02" ❑Other:
<br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. 0 IRRIGATION: 03/4" 01" 02" ❑Other:
<br /> ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER 0 FIRE: 01" 02" 04" 06" 08" ❑Other:
<br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER 0 DOMESTIC/FIRE COMBO: 01" 02" ❑Other:
<br /> SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. 0 BACKFLOW PREVENTION(Outside): ❑RPBA ❑DCDA ❑DCVA
<br /> OWNER NAME: 11,',Lc 1-4/1,•,) 5 pro f.// TENANT NAME(If Commercial):
<br /> OWNER MAILING ADDRESS: STREET
<br /> c��4."/ CITY STATE ZIP
<br /> OWNER PHONE: 286- 1 -766 2 OWNER EMAIL:
<br /> red
<br /> CONTRACTOR NAME: //',Lar /edno/l,,"e S
<br /> CONTRACTOR ADDRESS: STREET 28 2 .5 /54 Ph s /
<br /> CITY Se-"74.0 STATE L.4 ZIPcIio fie
<br /> CONTRACTOR PHONE: 4-1,S Sys) 70 CONTRACTOR EMAIL: •"--
<br /> CONTRACTOR
<br /> CONTRACTOR LIC #(REQUIRED): (/nC,ZGO/R' hZ CITY OF EVERETT BUSINESS LIC.#(REQUIRED 0S324/
<br /> PRIMARY CONTACT: 0 OWNER Fr CONTRACTOR 0 OTHER(Please Specify)
<br /> CONTACT NAME: CONTACT PHONE: 2 s3_Sa -c7,9‘67
<br /> 6,4.,19 An j(,„y,,e CONTACT EMAIL:
<br /> AGREEMENT:The undersigned applicant agrees 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
<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.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/comply with the State Contractors Law 18.27 ROW and 296.200A WAC.
<br /> City of Everett Official Use Only
<br /> PERMIT#
<br /> ZSAC//cl U k`tbS r—C ) RI)
<br /> Owner/Authorized Agent Signature Date (Revised 10/12/2018)
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