3827 HIGH ST 2022-03-01 - Laserfiche WebLink

so. _ WATER I SEWER UTILITY PPUICATIIN 04s,"--1 '4 --- CITY CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P)425-257-8810 I FAX 425-257-8857 I (E) everetteps©everettwa.gov I www.everettwa.gov/permits j� PROJECT-� ,j� SITE INFORMATION�o PROJECT ADDRESS: O ()J7 14 ►l S)' C �1 I � ��I1 l/I 1 IF APPLICABLE: ❑ OUTSIDE CITY L ITS ❑ BUILDING AREA SF ❑ LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY #OF UNITS: ❑COMMERCIAL DINDUSTRIAL CHANGE OF USE? NO ❑YES, FROM TO UTILITY APPLICATION INFORMATION SEWER (check all that apply) WATER(check all that apply) SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION El SIDE SEWER ALTERATION ❑ COMPLETE SERVICE ❑ METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: O INSTALL BACKWATER VALVE(outside the building) ❑ SFR ❑ SIDE SEWER CAP-OFF ❑ MULTI-FAMILY-#OF UNITS: ❑ SIDE SEWER RECONNECTION 0 COMMERCIAL MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE: (circle desired size) ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR ❑ DOMESTIC: 3/4", 1", 2", OTHER: MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. El IRRIGATION: 3/4", 1", 2", OTHER: ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑ FIRE: 1", 2", 4", 6", 8", OTHER: SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER ❑ DOMESTIC/FIRE COMBO: 1", 2", OTHER: SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. CONTACT INFORMATION OWNER NAME: CI�,U t./2. 4 ,'Y 16-4 i y /1,0ZS . OWNER MAILING ADDRESS: STREET+ v1 01 l1 K'f. �j'C�( CITY CO,\;,�^e. '1" STATE VIJ�'., ' ZIP - ' 21) 1 OWNER PHONE: v OWNER EMAIL: CONTRACTOR NAME: A* P� k CONTRACTOR ADDRESS: STREETeora 1 V �f�,�� fi CITY STATE QUA, • ZIP �,0266 Ai"'CONTRACTOR PHONE:jirA OVA CO TRACTOR EMAIL: I I y kA VIM 1 e .1O e BIM CONTRACTOR LIC.#(REQUIRED): 11 ,0 I IP b CITY OF EVERETT BUSINLIC.#(REQUIRED): PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR ❑OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: 1, )(In - 21 06 YOU ' CONTACT EMAIL:Am( mvi id' 6 ,e, [ rbtt • AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title City of Eve Official Use Only 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to FEE time. The applicant further agrees, ., a con i. n precedent to receiving service that the utilities division shall have the right at any ' e,w' . t notic', to shut off o turn on the water supply for repairs,construction,and litk�D• nonpayment f ch r•-s or or an other reasona le cause.I am the owner,or I am authorized by the owner of this property to pe'rfor he wo hich applicatio is made,and I comply with the State Contractors Law 18.27 RCW and 29:200 WAC '� I IT# ` I O PERML wner/Authoriz •gent Sig1ature Date (Revised 10/12/2015)