905 34TH ST 2022-03-02 - Laserfiche WebLink

WATER I SEWER UTILITY 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 SITE / 1 INFORMATION� / PROJECT ADDRESS: 0 1)5- . tcbir - t VY(/1 J W Ul, • IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: EICOMMERCIAL ❑INDUSTRIAL CHANGE OF USE? j/,NO ❑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 ❑ METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: 0 INSTALL BACKWATER VALVE(outside the building) ❑ SFR ❑ SIDE SEWER CAP-OFF 0 MULTI-FAMILY-#OF UNITS: ❑ SIDE SEWER RECONNECTION 0 COMMERCIAL MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE: (circle desired size) O I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR ❑ DOMESTIC: 3/4", 1", 2", OTHER: MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. 0 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 0 DOMESTIC/FIRE COMBO: 1", 2", OTHER: SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. CONTACT INFORMATION tl I OWNER NAME: I l ` I `7) VIAinn G/U r5`� TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: A-d J 1�a,k ` e CONTRACTOR ADDRESS: STREET 1 ir'b a j• l 0 Y `°.'t CITY STATE A, a ZIP �,e CONTRACTOR PHONE:lYf � $...,0, CONTRACTOR EMAIL: 4\V,I v^ j�11i I e _ • Ml O6J `a p CONTRACTOR LIC.#REQUIRED : CITY OF EVERETT BUSIN LIC.#(REQUIRED):�4 o Il/X////9t`/A�/@t I.I _ t G�� 51,55(0 PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR El OTHER(Please Specify) CONTACT NAME: o CONTACT PHONE: ( 1 1 L '— 6 fi� 1 o \ A,: CONTACT EMAIL: % , 11 1 I/i/6yt id IN ( ,c " ri cy ilw A I .04144 AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal lode Title City of Everett 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,as a condition precedent to receiving service that the utilities division shall have 14 _Th the right at anytime,without notice to shut off do turn on the water supply for repairs,construction,and /-' nonpayment of charges or‘for any other reasonable cause.1 am the owner,or 1 am authorized by the owner of this property to perfornj the work for which application is made,and 1 comply with the State Contractors Law 18.27 PER IT RCW and 296.200A WAG.' . " U ) 14(33 „�� — bZ� Owner/Authorizetl,,Agentsignature Date (Revised 10/12/2015)