10103 1ST DR SE 2020-05-06 - Laserfiche WebLink

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: i()10', t St" Dr ...s - IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT BUILDING TYPE: ❑SFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑ACCESSORY. CHANGE OF USE? 0 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 INST 'L'A,TI2u ❑SIDE SEWER ALTERATION 0 COMPLETE SERVICE i tE I EIz ONI-IA'N l•" : 3 a , r � ,� �,,° I'..�I ,2019 BBB XNEW SIDE SEWER INSTALLATION `�12I1/ � SERVICE/METER USE: 9 11 o INSTALL BACKWATER VALVE(outside8the/buildingg �11Y1 P 0 SFR �i° E� I ❑SIDE SEWER CAP-OFF 0 MULTI-FAMILY-#OF UNITS ^Y OF EVER E.TT o SIDE SEWER RECONNECTION 0 COMMERCIAL Perm m € Si "tib'! I MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE:(provide cafes to support size choice) ❑'I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR 0 DOMESTIC: 03/4" 01" 02" ❑Other: MY`MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. 0 IRRIGATION: 03/4" 01" 02" ❑Other: ❑I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER 0 FIRE: ❑1" 02" 04" 06" 08" ❑Other: SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER 0 DOMESTIC/FIRE COMBO: 01" 02" ❑Other: SINGLE OWNERSHIP.FILL OUT REVERSE SIDE OF THIS FORM. 0 BACKFLOW PREVENTION(Outside): ❑RPBA ❑DCDA ❑DCVA CONTACT INFORMATION OWNER NAME: TENANT BUSINESS NAME(If Commercial): OWNER MAILING ADDRESS: STREET �f Q {� A \n �y /� Eve u L CITY L V/v J /J n J T STATE �II O ZIP 9 e 2©e OWNER PHONE: OWNER EMAIL: C CONTRACTOR NAME: A eo,iS ' i—j of L p1- p J CONTRACTOR ADDRESS: STREET /2 2_2_ h v y J J , J u/I / 03- E ©t3- j� f� E✓eR. /� CITY 7 q / y STATE ZIP 98 20 / CONTRACTOR PHONE: '7 2 5 `2 3 2-`2�9 7 CONTRACTOR EMAIL: �2 I?V2IV 4 ea12°St UeL/OnpRf..awl CONTRACTOR LIC.#(REQUIRED): ,6CO'V C 1-00'Q R. CITY OF EVERETT BUSINESS LIC.#(REQUIRED): PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: CONTACT EMAIL: , AGREEMENT:The undersigned applicant agrees .comply with all provisions of the Everett Municipal Code Title 14 Water and Sewer or such other rules and regulations now existing or which may be established from time .time.The applicant further agrees,as a condition precedent to receiving sen/ice that the utilities division shall have the right at any time,without notice,to s ,ff or turn• "h e water supply for repairs,construction,and nonpayment of charges or for any other reasonable cause.I am the owner,or I am authorized by the owner., his pr.perty t. .erform the work for which application is made,and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. te,o City of Everett Official Use Only � PERMIT# - 002 120/Y U 1 (7t. pg () )'2 Owner/Auth.. •.• =gnature Date (Revised 10/1212018)