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'IP,,,S,/'---_ ,e—A WATER / SEWER UTILITY APPLICATION <br /> I*►Niti 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©everettwagov I www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: .( 790 t6/vl tiV"t^_► , <br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# <br /> BUILDING TYPE: )SFR DTOWNHOUSE ODUPLEX DADU OMULTI-FAMILY-#OF UNITS: °COMMERCIAL °ACCESSORY: <br /> CHANGE OF USE? *O 0 YES, FROM TO <br /> UTILITY APPLICATION INFORMATION <br /> SEWER(check all that apply) WATER(check all that apply) <br /> 6., <br /> SIDE SEWER REPAIR <br /> 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 /> 0 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 /> D I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR 0 DOMESTIC: 03/4" 01" 02" °Other: <br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP, 0 IRRIGATION: 03/4" 01" 02" ❑Other: <br /> D I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER 0 FIRE: 01" 02" 04" 06" 08" DOther: <br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER 0 DOMESTIC/FIRE COMBO: 01" 02" DOther: <br /> SINGLE OWNERSHIP.FILL OUT REVERSE SIDE OF THIS FORM. 0 BACKFLOW PREVENTION(Outside): DRPBA DDCDA DDCVA <br /> CONTACT INFORMATION <br /> OWNER NAME: (Ark Oe_pr" 40,c TENANT BUSINESS NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET /7.4h2 Aypz4yd - / <br /> CITY <(1�/-6.V STATE 1/1 ZIP 6)gdr 1/ <br /> OWNER PHONE: OWNER EMAIL: <br /> CONTRACTOR NAME: 114. 044.4( i <br /> r ffC <br /> -CONTRACTOR ADDRESS: STREET K�^__o ' pi,�//� cd- <br /> CIN <br /> /1460041•44e-- <br /> V t4 4-� �.�- STATE �/1 ZIP 1 TV V <br /> CONTRACTOR PHONE: C�6J 6Zr—14 /� CONTRACTOR EMAIL: <br /> CONTRACTOR UC.#(REQUIRED): T1 -r`Ia&? CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 0022? <br /> PRIMARY CONTACT: D OWNER CONTRACTOR 0 OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: (T j ...--R:90 <br /> ///14(14e-4(14e- iCONTACT EMAIL: A 3 e8 O) )I a�AGREEMENT::The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title 14 Water and Sewer 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,ort 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 and 296.200A WAC. <br /> / 74 . 9City of Everett Official Use Only <br /> U \CA.673-./ PERMIT# (--)15 <br /> Owner/Authorized Agent Signature Date (Revised 10/12/2018) <br />