8230 XAVIER WAY 2022-03-24 - Laserfiche WebLink

WAR /SEWER UTILITY APPLICATION EVERETT WASHINGTON CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P) 425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I https://everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: 3o IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT # BUILDING TYPE: ❑SFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI -FAMILY-# OF UNITS: ❑COMMERCIAL ❑ACCESSORY CHANGE OF USE? ❑ NO ❑ YES, FROM TO UTILITY APPLICATION INFORMATION SEWER (check all that apply) WATER (check all that apply) ❑ SIDE SEWER REPAIR ❑ SIDE SEWER ALTERATION ❑ NEW SIDE SEWER INSTALLATION ❑ INSTALL BACKWATER VALVE (outside the building) ❑ SIDE SEWER CAP -OFF ❑ SIDE SEWER RECONNECTION 1 /L •c' (ti ❑ NEW WATER SERVICE INSTALLATION ❑ COMPLETE SERVICE ❑ METER ONLY SERVICE / METER USE: ❑ SFR ❑ MULTI -FAMILY - # OF UNITS: ❑ COMMERCIAL WATER SERVICE TYPE / SIZE: (provide calcs to support size choice) ❑ DOMESTIC: ❑3/4" ❑V 112" ❑Other : ❑ IRRIGATION: 113/4" ❑l" ❑2" ❑Other : ❑ FIRE: ❑l" 112" ❑4" ❑6" ❑8" ❑Other : ❑ DOMESTIC/FIRE COMBO: El 02" ❑Other : ❑ BACKFLOW PREVENTION (Outside): ❑RPBA ❑DCDA ❑DCVA MULTIPLE DOMESTIC WATER SERVICES REQUEST ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR MY MULTI -FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ 1 AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER SERVICES FOR MY MULTI -FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. CONTACT INFORMATION OWNER NAME: , f TENANT BUSINESS NAME (If Commercial): OWNER MAILING ADDRESS: STREET jC ,,,,"- , CITY STATE L,-,4 ZIP y.�„24 OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: w•r,-¢Lt,s d,Y .., "�- CONTRACTOR ADDRESS: STREET CITY s,1a,., _) L• STATE zip 4 CONTRACTOR PHONE: U-.L CONTRACTOR EMAIL: Al,Ii• 7 C ` CONTRACTOR LIC. #(REQUIRED): /oGL CITY OF EVERETT BUSINESS LIC. #(REQUIR ): PRIMARY CONTACT: ❑ OWNER ❑ CONTRACTOR ❑ OTHER (Please I y) CONTACT NAME: CONTACT PHO E: 5 - U ,_ C Ll CONTACT EMAIL: ,, 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, 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 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. City of Everett Official Use Only PERMIT # orized Agent Signature Date (Revised 411512019)