2625 RUCKER AVE 2022-05-12 - Laserfiche WebLink

WATER / SEWER UTILITY APPL CAT ON CITY OF EVERETT PERMIT SERVICES = Eir 3200 CEDAR STREET, EVERETT, WA 98201 (P)425-257-8810 I FAX 425-257-8857 I (E) everetteps©everettwa.gov I www.everettwa.gov/pelrnits — PROJECT SITE !INFO MATRON PROJECT ADDRESS: 242 N f AJ�t q. b 2.0 I IF APPLICABLE: ❑ OUTSIDE CITY LIMITS 0 BUILDING AREA SF ❑ LOT# ;BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: DCOMMERCIAL ❑INDUSTRIAL 'CHANGE OF USE? NO El YES, FROM TO UTi IIUBTY( APPLIICATBOE1 IjCEFOEvi[�a ATDOt I SEWER(check all that apply) WATER(check all that apply) ❑ SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION ❑ SIDE SEWER ALTERATION ❑ COMPLETE SERVICE ❑ METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: 14 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. 'OWNER CONT/ACT INFORMATION NAME: I�'e,' J ! ��I + C 1&O `J )I'-• .✓�-^:IY , _ OWNER MAILING ADDRESS: STREET I y 0 I l q I�t±) 4 F. CITY -136 WVV-i STATE k/1 `- ZIP' l F OIO`, OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: Alf p Pi . CONTRACTOR ADDRESS: STREET jii:ii Y pbIVI.Y outiv s t)• '® CITY 1 STATE WA . ZIP (I, -��"�,3) ��' CONTRACTOR PHONE: l j ''�QV CONTRACTOR EMAIL: l /V'i 'ii r` le, 01 ,); E'l) ��l CONTRACTOR LIC.#(REQUIRED): t L• 1, 1, 1, 6 CITY OF EVERETT BUSIN LIC.#(REQUIRED): ® 55(0 PRIMARY CONTACT: ❑OWNER ❑ CONTRACTOR ❑ OTHER(Please Specify) i CONTACT NAME: . CONTACT PHONE: CIVAN 61Zb—9921 a ivil6 't ��C�p 1 � CONTACTEMAIL: 10 all I t1 1 , ? > i '' AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title City of Ever:-t Official Use Only 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to e FEE time. The applicant further agrees, a con I' n precedent to receiving service that the utilities division shall have ,, „�� CrL the right at any e,w' . t notice,to shut off o turn on the water supply for repairs,construction, and 4 # Q nonpayment cf 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 pelrfor he wo hich applicatio is made,and I comply with the State Contractors Law 18.27 PERMIT# RCW and 296 200 WAC I wner/Authoriz•. .gent Sig,ature Date (Revised 10/12/2015)