718 105TH PL SE 2022-01-25 - Laserfiche WebLink

- WATER / SEWER UTILITY APPLICATION CITY OF EVERETT PERMIT SERVICES r V E R E T T 3200 CEDAR STREET, EVERETT, WA 98201 (P)425-257-8810 I FAX 425-257-8857 I (E) everetteps@everettwa.gov I https://everettwa.gov/permits WASHINGTON PROJECT SITE INFORMATION PROJECT ADDRESS: 7t l;�j ? ) S L IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR ❑TOWNHOUSE ODUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: OCOMMERCIAL ❑ACCESSORY CHANGE OF USE? ❑NO 0 YES, FROM TO UTILITY APPLICATION INFORMATION SEWER(check all that apply) WATER(check all that apply) SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION ❑SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: ❑ INSTALL BACKWATER VALVE(outside the building) 0 SFR ❑SIDE SEWER CAP-OFF 0 MULTI-FAMILY-#OF UNITS: ❑SIDE SEWER RECONNECTION ❑COMMERCIAL MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE: (provide calcs to support size choice) ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR ❑ DOMESTIC: 03/4" 01" 02" ❑Other: MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. 0 IRRIGATION: 03/4" 01" 02" ❑Other: ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER 0 FIRE: 01" 02" 04" 06" 08" ❑Other: SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER 0 DOMESTIC/FIRE COMBO: 01" 02" ❑Other: SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. ❑ BACKFLOW PREVENTION (Outside): ❑RPBA ❑DCDA ❑DCVA CONTACT INFORMATION OWNER NAME: Ut ._;,71 e TENANT BUSINESS NAME(If Commercial): OWNER MAILING ADDRESS: STREET 'I )'(? )i25 ,i? -56 CITY / .1,-k V Vtt"t STATE ZIP Cf RJS1 OWNER PHONE: T25.--' J 0 ''b '2i2 OWNER EMAIL: CONTRACTOR NAME: , 9 l�/j pCuM ;y� [k CONTRACTOR ADDRESS: 9 STREET peJ /(Q}}oJ JJK: CITY -��J- `.�/"' STATE 9.61o7 ZIP 1 CONTRACTOR PHONE: L4 L ,)5 1 157 I ;-7 CONTRACTOR EMAIL: r , CONTRACTOR LIC.#(REQUIRED): 0. vI ! 3. CITY OF EVERETT BUSINESS LIC.#(REQU1 ED):��- ,. ... .. _ .: PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: j e C , (0,c," CONTACT PHONE: CONTACT EMAIL: `36(7 . / c�Z 'c 5? ' 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 maybe 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 tum 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 ,r 6. PERMIT# '2-� C A 7 <--)(71,1_ —7 0 U 2,00c. COB Owner/Authorizec,Agent Signature Date (Revised 4/15/2019) v"'