9911 23RD AVE SE 2021-12-15 - Laserfiche WebLink

WATER / SEWER UTILITY APPLICATION CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P) 425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRE A 98208 IF APPLICABLE: ❑ OUTSIDE CITY LIMITS 0 BUILDING AREA / i> SF LOT # 28051700305600 BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX []MULTI -FAMILY-# OF UNITS: ❑COMMERCIAL OINDUSTRIAL CHANGE OF USE? 0 NO ❑ YES, FROM TO I UTILITY APPLICATION INFORMATION SEWER (check all that apply) I WATER (check all that apply) I ❑ SIDE SEWER REPAIR ❑ SIDE SEWER ALTERATION 0 NEW SIDE SEWER INSTALLATION ❑ INSTALL BACKWATER VALVE (outside the building) ❑ SIDE SEWER CAP -OFF ❑ SIDE SEWER RECONNECTION MULTIPLE DOMESTIC WATER SERVICES REQUEST ❑ NEW WATER SERVICE INSTALLATION ❑ COMPLETE SERVICE ❑ METER ONLY SERVICE / METER USE: ❑ SFR ❑ MULTI -FAMILY - # OF UNITS: ❑ COMMERCIAL WATER SERVICE TYPE / SIZE: (circle desired size) ❑ 1 AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR ❑ DOMESTIC: 3/4", 1", 2", OTHER: MY MULTI -FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ IRRIGATION: 3/4", 1", 2", OTHER: ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑ FIRE: 1", 2", 4", 6", 8", OTHER: SERVICES FOR MY MULTI -FAMILY DEVELOPMENT UNDER ❑ DOMESTIC/FIRE COMBO: 1", 2", OTHER: SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. CONTACT INFORMATION OWNER NAME: Silver Lake Water and Sewer DIStrICt TENANT NAME (If Commercial): OWNER MAILING ADDRESS: STREET 15205 41 st Avenue SE CITY Bothell STATE WA ZIP 98012 OWNER PHONE: (425) 337-3647 OWNER EMAIL: rqgilmore@slwsd.com CONTRACTOR NAME: CONTRACTOR ADDRESS: STREET CITY STATE ZIP CONTRACTOR PHONE: CONTRACTOR EMAIL: CONTRACTOR LIC. #(REQUIRED): CITY OF EVERETT BUSINESS LIC. #(REQUIRED): PRIMARY CONTACT: 0 OWNER ❑ CONTRACTOR ❑ OTHER (Please Specify) CONTACT NAME: Eric Delfel, P.E. PHONE: 206 284-0860 LCONTACT NTACT EMAIL: edelfel@g-o.Com AGREEMENT: The undersigned applicant agrees to 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 to 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 nonpayment of charges or for any other reasonable cause. I am the owner, or 1 am authorized by the owner of this property to perform the work for which application is made, and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. City of Everett Official Use Only PERMIT # S c' G ri, 3 .�3L U_ NO3— Owner/Authorized Agent Signature Date (Revised 912312016)