8811 4TH PL 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 ( (E)everetteps@everettwa.gov( www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: 4953, L . L-t - QL 5E- AzfTl— L C-263 -0'0 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? NINO 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: ��£�.,�,t�j j,�,J TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET 9S r�(7 CrrY �� STATE ZIP 9g oZ COs OWNER PHONE: Ci —�jS -0(177(D OWNER EMAIL: CONTRACTOR NAME.:.,. €:::€_`6T- CONTRACTOR CONTRACTOR ADDRESS: STREET 6.1f , I 4541c tn.)AA-1. /.3- CITY 4 STATE J4 ZIP ggf fl 3 CONTRACTOR PHONE: Rap -(`Q?)�, —I -200 CONTRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): - CITY OF EVERETT BUSINESS LIC.#(REQUIRED) 9 0 3°495 PRIMARY CONTACT: 0 OWNER -raCONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: a©c,,, \v11 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 FEE time.The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have �) the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and nonpay nbe se. m h , I z grope nt t peroft i marges the ork+rfor.r whichanyother applicationreasoalis madecau ,andla1tcomple yownerwithor theams StateauthoriContractorsedbythe Lawowner 18.27of this PERMIT# RCWa 296..i0A W• 1O—q-6 U c oo ~M5 Owe Authorized A•e t Si• . ure Date (Revised 10/12/2015)