3528 HOYT AVE 2019-09-23 - Laserfiche WebLink

Al)11.1°P-4,41t,,,,--A ' WATER / SEWER UTILITY APPLICATION CITY OF EVERETT PERMIT SERVICES vr1 3200 CEDAR STREET, EVERETT, WA 98201 (P)425-257-8810 I FAX 425-257-8857 I (E) everetteps@everettwa.gov I www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: evii) 1-4--Ev9--- IFF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: 0 SFR-DETACHED ❑SFR-ATTACHED 0 DULEX 0 MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL 0 INDUSTRIAL CHANGE OF USE? NO 0 YES, FROM TO UTILITY APPLICATION INFORMATION SEWER(check all that apply) WATER(check all that apply) ❑SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION ❑SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: INSTALL BACKWATER VALVE(outside the building) 0 SFR ❑SIDE SEWER CAP-OFF 0 MULTI-FAMILY-#OF UNITS: - ❑SIDE SEWER RECONNECTION 0 COMMERCIAL MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE: (circle desired size) ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR 0 DOMESTIC: 3/4", 1", 2", OTHER: MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. 0 IRRIGATION: 3/4", 1", 2", OTHER: ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER 0 FIRE: 1", 2", 4", 6", 8", OTHER: SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER 0 DOMESTIC/FIRE COMBO: 1", 2", OTHER: SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. CONTACT INFORMATION OWNER NAME: TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: A' P[tvivilm . CONTRACTOR ADDRESS: STREET klll 1 Nit iV / • CITY STATE Wal, e ZIP 0(02406 // ,^ CONTRACTOR PHONE:!.1''6 L„JJ) 'V Dr2A GO TRACTOR EMAIL: \ bl ''// l Y./ .✓l OaYr i{Il,( iC.('/t' t CONTRACTOR LIC.#(REQUIRED): 1 1 ,, P CITY OF EVERETT BUSINr LIC.#(REQUIRED) A �d 6 y. PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: (../LOS''' 1 j 6 -61921 61921 e ve\lE \ '�1 I CONTACT EMAIL: /} (11414, I ( iC '" ' `0� AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal de Title City of Everitt Official Use Only g PP �l ,w 14 Wafer and Sewer or such other rules and regulations now existing or which may be established from time to FEE �� time. The applicant further agrees, a con i" n precedent to receiving service that the utilities division shall have4 the right at any ' e,w" • t notice to shut off o turn on the water supply for repairs,construction, and nonpayment. ch-r.-s or or ani other reasona le cause.I am the owner,or I am authorized by the owner of this property top- or he wo hich applicatio is made,and I comply with the State Contractors Law 18.27 PER I # Q RCW and 29:200 WAC ' u 'P( ©- / i 5 ,� Il (J` Owner/Authoriz- �•gent Sig,ature Date (Revised 10/12/2015)