6303 ROCKEFELLER AVE 2016-05-26 - Laserfiche WebLink

4terr WATER / SEWER UTILITY APPLICATION CITY OF EVERETT PERMIT SERVICES 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: a ?r,i }2 o e,i(�pe/lam Y Ave_ Lit e -Y t/- td4 ?6.20 IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? ❑ NO ❑YES, FROM TO UTILITY APPLICATION INFORMATION SEWER(check all that apply) WATER(check all that apply) SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION 0 SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY 0 NEW SIDE SEWER INSTALLATION SERVICE/METER USE: ❑ INSTALL BACKWATER VALVE(outside the building) 0 SFR 0 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: 0 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: f 1 a)Y1 ; c J ,1 Yc c_c TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET tc, O 3 A ter^tc —F-r Iii r ,A1(//'' CITY 4_ STATE (A f, ZIP O u 2 p�� l� I/ ( OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: SdOrb i b/r J CONTRACTOR ADDRESS: STREET A S/w) LaS S CITY re /X r Tf STATE � ZIP 9 �{/� CONTRACTOR PHONE: 2„ �_ 7 �� _/7_9- ( !J CONTRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): ('C#. "5 )p U J Go 7:-/c6 CITY OF EVERETT BUSINESS LIC.#(REQUIRED): UV7 1290 PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR ❑OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: '7 1 _ �(� `,// 7 T o o4A,)L yacgc CONTACT EMAIL: AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title City of Everett Official Use Only 14 Water and Sewer or such other rules and regulations now 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 FEE ' -' C,L the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and ' F)U 4 nonpayment of charges or for any other reasonable cause.I am the owner,or/am authorized by the owner of this property to perform the work for which application is made,and/comply with the State Contractors Law 18.27 PERMIT# RCd 296. A WAC. 022n A 6, A6 _ U thorizSignature Date (Revised 10/12/201 5)