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/1.1P WATER / SEWER UTILITY APPLICATION
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<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 www.everettwa.gov/permits
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<br /> PROJECT ADDRESS: • ' ' • '0 Ai * ' ' ter- .....* #.p. •
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<br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS . 0 BUILDING AREA SF 0 LOT#.
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<br /> BUILDING TYPE: . CoSPR II1TOVVNHOUSE ODUPLEX OADU 1:7MULTI-FAMILY-#OF UNITS:.:,, E1COMMERCIAL 0ACCESSORY
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<br /> CHANGE OF USE? 0 NO DYES, FROM TO
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<br /> SEWER(check all that apply) . ' WATER(check all that apply)
<br /> • SIDESEWER REPAIR
<br /> isite,r/
<br /> I=1 NEW WATER SERVICE INSTALLATION
<br /> El SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY
<br /> 0 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 /> 0 SIDE SEWER RECONNECTION 0 COMMERCIAL.
<br /> MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE:(provide calcs to support size choice)
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<br /> El I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR 0 DOMESTIC: 03/4" 01" 02" 00ther:
<br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP, 0 IRRIGATION: 03/4" Di" 02" 00ther:
<br /> 0 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): ORPBA 0DCDA 0DCVA
<br /> ' - '":•''''‘‘ 27',:‘,Z11,, - cot*140.wikAtortititATiow, ,,, $f---i-,-::-w'-, :ii
<br /> OWNER NAME: Pc;tjeci ( -iii,,e, , TENANT BUSINESS NAME(1fcor...r.i.9;
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<br /> OWNER MAILING ADDRESS: STREET
<br /> - (-3•9‘C2 , Kre)Likzgellek- Aii". ... 5''' B'
<br /> cny rt;fe
<br /> 10re. STATE 21E- 98.2„0 L.
<br /> OWNER PHONE: 2 5 790 g&--/ .,,,1?WNER EMAIL: $+AA. ak,.@ CI1:j1 # Larn
<br /> CONTRACTOR NAME: M.
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<br /> CONTRACTOR ADDRESS: STREET 2000 3 i f(j1+) St-
<br /> crrySTATE ZIP 2
<br /> CS €L4+it t4'''S) Iiiik"
<br /> COtATFtACTOR PHONE: ,g0t,f,tlIct (..Q(1 11 CONTRACTOR EMAIL: csficAA—tizIvit@ rywrcyr)4er-Sect.( I
<br /> CONTRACTOftLIC.IRREQUIRED): Pr V•Of's- C)2.74.1(.4\1 CITY OF EVERETT BUSINESS LIC.44REQuiRem: 6#
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<br /> PRIMARY CONTACT: 0 OWNER WI ONTRACTOR 0 OTHER(Please Specify)
<br /> C'MATlAiCtT NAME: CONTACT PHONE:: l6._2al4,,„ ir2,..,7/ i
<br /> / CONTACT EMAIL
<br /> AGREEMENT:The undersigned applicant tome:to.. ply with all provisions of the Everett Municipal Code Title 14 Water arid Sewer or such other rules and regulations now
<br /> existing or which may be established from time to : The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have the right at
<br /> anytime,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 /> the owner of this property to gerf., the work for which application is made,and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC.
<br /> City of Everett Official Use Ort6e
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<br /> U ' st 2 , 2 ri--
<br /> PERMIT#
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<br /> ,,,.., . f Att, er , f )4e 4:2 ,
<br /> ovniertAut °tiled Agent:..t nature Date (Revised 10/12/2018)
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