1030 RUCKER AVE 2022-03-02 - Laserfiche WebLink

• WATER / SEWER U HI Y APPLICATION] 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 PROJECT� SETE INFORI AT ION !PROJECT ADDRESS: `4� eXik X .,V OAi L IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA. SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL i 'CHANGE OF USE? NO ❑YES, FROM TO UTILITY L [ 'LIlCAT LION INFO MATZO 9 SEWER (check all that apply) WA o Ei" (check all that apply) IA SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION ❑ SIDE SEWER ALTERATION 0 COMPLETE SERVICE ❑ METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: 0 INSTALL BACKWATER VALVE(outside the building) ❑SFR ❑SIDE SEWER CAP-OFF ❑ MULTI-FAMILY-#OF UNITS: ❑ SIDE SEWER RECONNECTION ❑ 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. ❑ 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 INFORMAT60N OWNER NAME: (1,U 16.4 4\�r l k. c•(kyylva,1--- If Commercial): OWNER MAILING ADDRESS: STREET I 0310 J'V,C Q/y 0-'Qi }�Q CITYAL' STATE W(/I ZIP.1S ) OWNER PHONE: OWNER EMAIL: 'CONTRACTOR NAME: 41 i P.AVikkti,s,,, CONTRACTOR ADDRESS: STREET �i � eh 1V M4 ittroo `,, CITY STATE WA, o ZIP ot o CONTRACTOR PHONE:iJ4 n-' -!� �. 01?A CONTRACTOR EMAIL:"*A,IA tA,1��b1 1 , 11j O Al CONTRACTOR LIC.#(REQUIRED): (: �14 I/ 1. i. P) CITY OF EVERETT BUSIN LIC.#(REQUIRED): ®�. 5157 PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 0 OTHER(Please Specify) ^r CONTACT NAME: . CONTACT PHONE: Li!✓'J 1 Lb 'ci 21 ril6 PAM\ Yf CONTACT EMAIL: a� _41rl ( C 1® AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal de Title City of Evert Official Use Only 14 Water and Sewer or such other rules and regulations now existing or which maybe established from time to PEE time.The applicant further agrees, . a con. 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 4 ' (f° nonpayment. ch.' .-s or or an other reasona le cause.I am the owner,or l am authorized by the owner of this property to p= or he wo hich applicatne is made,and I comply with the State Contractors Law 18.27 f PERMIT# RCW and 29:200 I C ' Igo -Owner/Authoriz•b ;gent Sig,ature Date (Revised 10/12/2015 )