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WATER / SEWER UTILITY APPLICATION <br />CITY OF EVERETT PERMIT SERVICES <br />EVERETT <br />WASHINGTON <br />SUBMITTAL INSTRUCTIONS: Drop off hard copy paper application & plans to 3200 Cedar Street 2nd Floor Intake Drop Box. <br />CONTACT INFORMATION: (P) 425-257-8810 1 (E) PermitServices@everettwa.gov I (W) everettwa.gov/permits <br />PROJECT SITE INFORMATION <br />1 <br />PROJECT ADDRESS: l SS—S <br />n v <br />IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT # <br />BUILDING TYPE: ' R ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI -FAMILY-# OF UNITS: ❑COMMERCIAL ❑ACCESSORY <br />��lCHANGE <br />OF USE? El NO ❑ YES, FROM TO <br />UTILITY APPLICATION INFORMATION <br />SEWER (check all that apply) <br />VI_ <br />WATER (check all that apply) <br />DE SEWER REPAIR <br />SIDE SEWER ALTERATION v LO!✓� <br />❑ NEW SIDE SEWER INSTALLATION <br />❑ INSTALL BACKWATER VALVE (outside the building) <br />❑ SIDE SEWER CAP -OFF RLQA/ -� �� <br />❑ SIDE SEWER RECONNECTION <br />ElBACKFLOW PREVENTION (Outside) - Specify device type below: <br />❑RPBA (dom.) ❑DCVA (dom.) ❑DCVA (irr.) ❑DCDA (fire) <br />❑ WATER LINE BEHIND METER (repair or alteration) <br />❑ NEW WATER SERVICE INSTALLATION <br />Specify installation type below: <br />❑ NEW COMPLETE SERVICE <br />❑ METER ONLY <br />Specify water service type & size below: <br />❑ DOMESTIC: 113/4" ❑1" 112" ❑Other : <br />❑ IRRIGATION: 113/4" 111" ❑2" ❑Other : <br />❑ FIRE: ❑l" 112" ❑4" 136" 118" ❑Other : <br />❑ DOMESTIC/FIRE COMBO: ❑l" 112" ❑Other : <br />MULTIPLE DOMESTIC WATER SERVICES REQUEST <br />❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR <br />MY MULTI -FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. <br />❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER <br />SERVICES FOR MY MULTI -FAMILY DEVELOPMENT UNDER <br />SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. <br />CONTACT INFORMATION <br />OWNER NAME: DC r�, 0 ( < TENANT BUSINESS NAME (If Commercial): <br />OWNER MAILING ADDRESS: STREET <br />CITY STATE ZIP <br />OWNER PHONE: <br />OWNER EMAIL: 0C V1 L(y) WW gDCc S M h t.L <br />CONTRACTOR NAME: L j <br />CONTRACTOR ADDRESS: STREET <br />CITY STATE <br />CONTRACTOR PHONE: <br />CONTRACTOR EMAIL: <br />CONTRACTOR LIC. #(REQUIRED): <br />CITY OF EVERETT BUSINES <br />#(REQUIRED <br />PRIMARY CONTACT: ❑ OWNER ❑ CONTRACTOR ❑ OTHER (Please Specify) <br />CONTACT NAME: <br />De,�) pe flc7 (mot / <br />CONTACT PHONE: CITY OF EVERETT <br />CONTACT EMAIL: Permit Services <br />AUKLLMtiv i s i ne unoersigneo 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. / 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 and 296.200A WAC. <br />City of Everett Official Use Only <br />J PERMI) <br />Owner/Authorize iEn� gnature Date (Revised 412112022) <br />