1624 127TH PL SE 2020-05-22 - Laserfiche WebLink

MI WATER 1 SEWER UTILITY APPLICATION LI EVERETT 32CITY OF EVERETT PERMIT SERVICES 00 CEDAR STREET,EVERETT,WA 98201 WASHINGTON (P)425-257-8810 I FAX 425-257-8857 I(E)everettepso(,,,jeverettwa.gov I www.everettwa.govlpermits PROJECT SITE INFORMATION PROJECT ADDRESS: 1(02,4- 12- 141 p L- °- I- g2- `> IF APPLICABLE: ❑OUTSIDE CITY LIMITS ❑ BUILDING AREA SE I LOT# BUILDING TYPE: $SFR ❑TOWNHOUSE L1DUPLEX E ADU ❑MULTI-FAMILY-#OF UNITS: m [ COMMERCIAL ❑ACCESSORY' CHANGE OF USE? ❑NO ❑YES, FROMTO UTILITY APPLICATION INFORMATION SEWER(check all that apply) WATER(check all that apply) ❑SIDE SEWER REPAIR ❑NEW WATER SERVICE INSTALLATION ❑SIDE SEWER ALTERATION ❑COMPLETE SERVICE ❑METER ONLY NEW SIDE SEWER INSTALLATION SERVICE/METER USE: ❑INSTALL BACKWATER VALVE(outside the building) ❑SFR ❑SIDE SEWER CAP-OFF ❑MULTI-FAMILY-#OF UNITS: ❑SIDE SEWER RECONNECTION ❑COMMERCIAL MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE I SIZE:(provide calcs to support size choice) ❑I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR ❑DOMESTIC: 03/4" ❑1" 02" ❑Other: MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑IRRIGATION: 03(4" ❑1" ❑2" ❑Other: ❑I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER El FIRE: ❑i" 02" 04" 06" 08" ❑Other: SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER ❑DOMESTIC/FIRE COMBO: ❑1" 02" ❑Other; SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. ❑BACKFLOW PREVENTION(Outside): ❑RPBA ❑DCDA ❑DCVA w CONTACT INFORMATION OWNER NAME: "z ,;:{ - ,) TENANT BUSINESS NAME(If Commercial):. OWNER MAILING ADDRESS: STREET 0024 12-.Ti 41 pt..... 5� 6e2 crrY STATE WA 71P .96'206 OWNER PHONE: 4l en 1 1,53.;;::, OWNER EMAIL L't 4-gr,---41 —' , ,— I I I i-e. t C411i CONTRACTOR NAME: i7R'Mc1LI I IC:tD@ CONTRACTOR ADDRESS: STREET E?7,72 )0 kiIi,Kj2--/ W VIA �A CITY t(+.ate STATE.... . VIA ZIP q 150ii 2 CONTRACTOR PHONE: 21"a> ' •.3' • C) CONTRACTOR EMAIL I el' ;,e, - dock,,0e.,4 ,tG CONTRACTOR LIC,#(REQUIRED( t2 j)-I op I f CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 4- t PRIMARY CONTACT: (OWNER ❑CONTRACTOR ❑OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: CONTACT EMAIL: AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title 14 Water end 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,arid nonpayment of charges or for any other reasonable causelam the owner,or I am authorizedy ire owner of this•roperly to perform the work for which application is made,and I comply with the State Contractors Law 18.27 RCW end 296.200A WAC. "),,,. Oily of Everett Official Use Only PERMIT#' .. tf I Owner/ uthorized '• he Signature Oat (Revised 10/12/2018)