1415 112TH ST SE 2021-12-13 - Laserfiche WebLink

WAOM o SEWER UTUTY R LICAT O 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 www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: m ` n ti l • sg a , $� IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT # BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX []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 ❑ SIDE SEWER ALTERATION ❑ NEW SIDE SEWER INSTALLATION 0 INSTALL BACKWATER VALVE (outside the building) ❑ SIDE SEWER CAP -OFF ❑ SIDE SEWER RECONNECTION I MULTIPLE DOMESTIC WATER SERVICES REQUEST ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR MY MULTI -FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER SERVICES FOR MY MULTI -FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. ❑ NEW WATER SERVICE INSTALLATION ❑ COMPLETE SERVICE SERVICE / METER USE: ❑ SFR ❑ METER ONLY �i''Cf*_�u ❑ MULTI -FAMILY - # OF UNITS: ❑ COMMERCIAL WATER SERVICE TYPE / SIZE: (circle desired size) ❑ DOMESTIC: ❑ IRRIGATION: FIRE: V, 2", ❑ DOMESTIC/FIRE COMBO 3/4", 1", 2", OTHER: 3/4". 1 ". 2". OTHER: 4", a 8", OTHER: 1", 2", OTHER: CONTACT INFORMATION OWNER NAME: ��'�, TENANT NAME (If Commercial): OWNER MAILING ADDRESS: STREET IV DOJl CITY 1 ��//� /� STATE V (/Y l • zip � f�j X fe OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: CONTRACTOR ADDRESS: STREET CITY STATE e zip CONTRACTOR PHONE: Qj®DI CONTRACTOR EMAIL: AA MA e CONTRACTOR LIC. #(REQUIRED): CITY OF EVERETT BUSIN LIC. #(REQUIRED): PRIMARY CONTACT: ❑ OWNER ❑ CONTRACTOR ❑ OTHER (Please Specify) CONTACT NAME: CONTACT PHONE: e CONTACT EMAIL: ds 6 A 1 a e 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, ps c nd*, precedent to receiving service that the utilities division shall have the right at any e, wi t noticJ, to shut off of turn on the water supply for repairs, construction, and nonpayment s or or an other reasonaole cause./ am the owner, or I am authorized by the owner of this property to p or he wo r hich applicatio is made, and I comply with the State Contractors Law 18.27 RCW and 29200 WA C f a r\ Igo i SicorYature Date City of Ever&it Official Use Only FEE PERMIT# U (? nc)�— old (Revised 1011212015)