BLD2021-0094-Water Availability Application-11.23.2021<( Of EV tfo4/
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SECTION A
WATER AVAILABILITY APPLICATION
Complete and submit this form to EngineeringPermitsPedmondswa.gov
Applicant Information
Contact/Applicant Name
Phone Number
Email 4
Address
City
State
zip D 7
�_o
Property Information
Project Name
Associated Permit Number ` _
4
Address /—. 1410
City Q
State
zip Gq
Parcel No. lo�b �� O
Does the property currently have water service? p<Ves (City of Edmonds water) ❑ No
Describe project
In what phase is the project?
❑ Design Review Building Permit
❑ Preliminary Plat ❑ Rezone or Other
Associated permit application number(s), if applicable: t�
SECTION B
A -Applicant certifies that this project is a single-family residence or short plat subdivision (four lots or
less), in which case completion of a full utility availability study shall not be required. Please sign below
and submit this form to EngineeringPermits(&edmondswa.gov.
❑ For all other permit types, a u ' rty vailability study is required and associated fees will be due. Please
submit the complete appl'c io o E ineerin Permits edmondswa. ov.
APPLICANT SIGNATURE: DATE:
0eeAPPLICANT PRINTED NAME:
Form Updated 09/02/2021