2127 ROCKEFELLER AVE 2020-07-15 - Laserfiche WebLink

WATER / SEWER TILfY APPUGATON CITY OF EVERETT PERMIT SERVICES EVERETT 3200 CEDAR STREET, EVERETT, WA 98201 (P) 425-257-8810 I FAX 425-257-8857 1 (E) everetteps@everettwa.gov I https://everettwa.gov/permits WASHINGTON PROJECT SITE INFORMATION PROJECT ADDRESS; (V1 Dale/et -642 IF APPLICABLE: ❑ OUTSIDE CITY LIMITS El BUILDING AREA SF El LOT# BUILDING TYPE: ❑SFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑ACCESSORY CHANGE OF USE? 0 NO El YES, FROM TO UTILITY APPLICATION INFORMATION SEWER (check all that apply) WATER(check all that apply) SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION El SIDE SEWER ALTERATION El COMPLETE SERVICE ❑ METER ONLY El NEW SIDE SEWER INSTALLATION SERVICE/METER USE: El INSTALL BACKWATER VALVE (outside the building) El SFR El SIDE SEWER CAP-OFF El MULTI-FAMILY-#OF UNITS: El SIDE SEWER RECONNECTION El COMMERCIAL MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE: (provide calcs to support size choice) El I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR ❑ DOMESTIC: ❑3/4" ❑1" 02" ❑Other: MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. El IRRIGATION: 03/4" Eli" 02" ❑Other: ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER El FIRE: 01" 02" 04" 06" 08" ❑Other: SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER ❑ DOMESTIC/FIRE COMBO: Eli" 02" ❑Other: SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. ❑ BACKFLOW PREVENTION (Outside): ORPBA ❑DCDA ❑DCVA CONTACT INFORMATION OWNER NAME: TENANT BUSINESS NAME(If Commercial): OWNER MAILING ADDRESS: STREET CITY STATE Z!P OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: , vik) CONTRACTOR ADDRESS: STREET CITY STATE ZIP CONTRACTOR PHONE: CONTRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED): PRIMARY CONTACT: El OWNER El CONTRACTOR ❑ OTHER(Please Specify) COIJTACT NAME: CONTACT PHONE: ' 7 ? ? S.30 S© ; - R c env- -- CONTACT EMAIL: AGREEMENT:The undersigned applicant agrees to comply with all. r visions 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 appl'-. 'rrther agrees,as a condition precedent to receiving service that the utilities division shall have the right at any time,without not , shut off or turn on the water ..p. for r••-irs,construction,and nonpayment of charges or for any other reasonable cause.I am the owner, or I am authorized by the ow of this property to perform t e w. fo • 't-pplication is made,and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. City of Everett Official Use Only PERMITC# Owner thorized Agent Signature :te (Revised 4/15/2019)