2219 PINEHURST AVE BASE FILE 2020-07-14

4err W 'ER / SEWER UTILITY APPLICATION CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P) 425-257-8810 I FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits 09 PROJECT SITE INFORMATION PROJECT ADDRESS: )LX. tl W '1jg.-s(1- I 0 ZO 3 IF APPLICABLE: 0 OUTSIDE CITY LIMITS ❑ Bek.bIVG AREA�O07 SF 0 LOT# 3) — 3 2— BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED NtIDULEX ❑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 L)Q NEW WATER SERVICE INSTALLATION ❑ SIDE SEWER ALTERATION IgCOMPLETE SERVICE ❑ METER VI,tlEW 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/SIZE: (circle desired size) O I 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: O 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. BACKFLOW PREVENTION (outside): [PBAfDCDA UDCVA �1� CONTACT INFORMATION OWNER NAME: ,U 14( Wt Ec1y 1 n -((/ TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET tai �/�Q��J�/{r� me t, w 'j ( STh 'J/D0 �/ CITY �*VOV ✓'1 STATE ZIP I Y`o 4- OWNER PHONE: (42'5') +2,2-3100 OWNER EMAIL: &IA nl-N30 p vu-t- .(Avyv► CONTRACTOR NAME: IF LAW-Mit-12- Mt. 6 Ij.,t/Cj CONTRACTOR ADDRESS: STREETI P.O. f60y,. '2A 2- CITY �'J D 0D)t4\/I Vl/V- STATE ( ZIP g o 7 CONTRACTOR PHONE:(2'Q(/) t00 - 114 47 CONTRACTOR EMAIL: 4,,,,, ,N k+ ' S(? ov,Nook.c vv\ CONTRACTOR LIC.#(REQUIRED): PLAT i4 1.-W04 CITY OF EVERETT BUSINESS LIC.#(REQUIRED): PRIMARY CONTACT: 0 OWNER ❑ CONTRACTOR ' OTHER (Please Specify) GOIrv' r A-14)2y AV CONTACT NAME: CONTACT PHONE:,(4..i ) ',c _ R1016 CONTACT EMAIL: G ve,,,,[6 „a em"t neGi'S, 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,t 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 I am authorize by the r 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 12-11/b$ PERMIT# Owner/ t izticti Agent Signature Date (Revised 8/2/2018)