5123 27TH AVE W 2020-06-18 - Laserfiche WebLink

WATER / SEWER UTILITY APPLICATION I* ' - CITY OF EVERETT PERMIT SERVICES "�1M�� 3200 CEDAR STREET, EVERETT, WA 98201 (P)425-257-8810 I FAX 425-257-8857 1 (E) everetteps@everettwa.gov www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: Th FYV IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED USER-ATTACHED ODULEX ❑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 ❑ SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY O 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: O I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER 0 F- 1", 2", 4", 6", _ OTHn ❑ SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER 0 ■•' STIC/FIRE COMBO: 1", 2", OTHER: SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. 0 BACKFLOW PREVENTION(outside): RPBA DCDA DCVA CONTACT INFORMATION OWNER NAME: 14I-- 1 f''jcrryi TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET 1 2 5 2, 7'11 "V f� CfTY STATE ZIP / +)t��. 7�t�,�2.V(3 OWNER PHONE: T -3/ 9 70 4,.(4-1) OWNER EMAIL: Om_cAr Y`^. CtJ"r. g ...S4. CONTRACTOR NAME: .,,,,�1 f ()S —.‘ \f diba ,yr- p.- CONTRACTORADDRESS: STREET 0%}(',`rJ,`i yS} 1 t (/ '' �. .V v- ..... (� It) CITY i—H ` . STATE ` !" 7M CONTRACTOR PHONE: tom,Q r • Q9 I CONTRACTOR EMAIL: mg 40,f CONTRACTOR LIC,#(REQUIRED): 11/440Z Of24 02240 C, CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 3S cks 0 PRIMARY CONTACT: 0 OWNER CONTRACTOR 0 OTHER(Please Specify) coprIA T NAME: CONTACT PHONE: (es--1 c. 9,1 1 LarvCONTACT EMAIL: j A, ' AAI ..��T� �' ; tit. 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,wi hoot notice,to shut off or turn on the wet..,supply for repairs,construction,and nonpayment of charges or for any other reasonable cause.I am the owner,or I am au tiz by t e owner of this prope>y to pert* .1the 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 1 FERMI YA, # . 0. ' 0 t / /�, ' -- `-� l 1 0 1 'bwrraf7Authorized Agy`rst Signature Date (Revised 8/2/2018)