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0 40 <br />WATER / SEWER UTILITY APPLICATION <br />EVERETT <br />WASHINGTON <br />CITY OF EVERETT PERMIT SERVICES <br />3200 CEDAR STREET, EVERETT, WA 98201 <br />(P) 425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov 1 www.everettwa.gov/permits <br />PROJECT SITE INFORMATION <br />PROJECT ADDRESS: 2906 47th St SE, Everett, WA <br />IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑✓ BUILDING AREA 2729 SF ❑ LOT # 365 <br />BUILDING TYPE: ❑✓ SFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI -FAMILY-# OF UNITS: ❑COMMERCIAL ❑ACCESSORY <br />CHANGE OF USE? ❑ NO ❑ YES, FROM TO <br />I UTILITY APPLICATION INFORMATION I <br />SEWER (check all that am)ly) I WATER (check all that apply) <br />❑ SIDE SEWER REPAIR <br />❑ SIDE SEWER ALTERATION <br />❑✓ NEW SIDE SEWER INSTALLATION <br />❑ INSTALL BACKWATER VALVE (outside the building) <br />❑ SIDE SEWER CAP -OFF <br />❑ SIDE SEWER RECONNECTION <br />MULTIPLE DOMESTIC WATER SERVICES REQUEST <br />❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR <br />MY MULTI -FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP <br />❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER <br />SERVICES FOR MY MULTI -FAMILY DEVELOPMENT UNDER <br />SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. <br />❑✓ NEW WATER SERVICE INSTALLATION <br />❑ COMPLETE SERVICE ❑ METER ONLY <br />SERVICE / METER USE: <br />❑ SFR <br />❑ MULTI -FAMILY - # OF UNITS: <br />❑ COMMERCIAL <br />WATER SERVICE TYPE / SIZE: (provide calcs to support size choice) <br />❑✓ DOMESTIC: ❑✓ 3/4" Or ❑2" ❑Other : <br />❑ IRRIGATION: ❑3/4,, ❑v ❑2" ❑Other : <br />❑ FIRE: 01" 02" ❑4" ❑6" ❑8" ❑Other : <br />❑ DOMESTIC/FIRE COMBO: ❑l- ❑2" ❑Other : <br />❑ BACKFLOW PREVENTION (Outside): ❑RPBA ❑DCDA ❑DCVA <br />CONTACT INFORMATION <br />OWNER NAME: Polygon WLH, LLC TENANT BUSINESS NAME (If Commercial): <br />OWNER MAILING ADDRESS: STREET 11624 SE 5th Street, Suite 100 <br />CITY Bellevue STATE WA ZIP 98005 <br />OWNER PHONE: 425.586.7700 <br />OWNER EMAIL: connor.king@polygonhomes.com <br />CONTRACTOR NAME: Same as Owner <br />CONTRACTOR ADDRESS: STREET <br />CITY STATE ZIP <br />CONTRACTOR PHONE: 425.586.7700 <br />CONTRACTOR EMAIL: connor.king@polygonhomes.com <br />CONTRACTOR LIC. #(REQUIRED): polygwl863pw <br />CITY OF EVERETT BUSINESS LIC. #(REQUIRED): 053222 <br />PRIMARY CONTACT: ❑✓ OWNER ❑ CONTRACTOR ❑ OTHER (Please Specify) <br />CONTACT NAME: <br />Connor King <br />CONTACT PHONE: 425.586.7700 <br />CONTACT EMAIL:connor.king@polygonhomes.com <br />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 <br />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 <br />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 I am <br />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. <br />City of Everett Official Use Only <br />8/27/19 <br />PERMIT ## _� D'� 0 <br />U 1 " I I o <br />Owner/Authorized Agent Si nature <br />Date <br />(Revised 1011212018) <br />