1712 22ND ST 2022-05-18 - Laserfiche WebLink

WATER I SEWER UTUTY APPLICA O ''.411d4::::g ' CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P)425-257-8810 I FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits PROJECT SINE INFORMATION PROJECT ADDRESS: \�i / " ' 617 — v gj I IF APPLICABLE: ❑ OUTSIDE CITY LIMITS 0 BUILDING AREA SF ❑ LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? ii NO ❑YES, FROM TO UTIUITY APPE,ICATIOI IE` FORM TI® SEWER(check all that apply) WATER(check all that apply) I SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION ❑ SIDE SEWER ALTERATION ❑ COMPLETE SERVICE ❑ METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: It INSTALL BACKWATER VALVE(outside the building) ❑ SFR ❑ SIDE SEWER CAP-OFF ❑ MULTI-FAMILY-#OF UNITS: ❑l 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 El 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: 3ak 10/AYA VOA() Vit TENANT NAME(If Commercial): '2 OWNER MAILING ADDRESS: STREET 11 2 3-1- CITY TCITY �i/VC _sOM, ,0 S-26 STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: iA- P,144410) it T CONTRACTOR ADDRESS: STREETextra I \ti 14771141/0 hf 1 CITY STATE t,1I%A . ZIP / �� CONTRACTOR PHONE: �� DOA CO TRACTOR EMAIL: ,p /�tI 11 1 � �i U474 ,1 I I i CONIA TRACTOR LIC.#(REQUIRED): L CITY OF EVERETT BUSINS LIC.#(REQUIRED): Q PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: . CONTACT PHONE: Ll �In-9921 116 WI\, Il` I l-%' CONTACT EMAIL: 4. ' ' [ 'C 6 'p�t3' I AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title - City of Evert 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 coni precedent to receiving service that the utilities division shall have l the right at any ' e,w' • t notice,to shut off o turn on the water supply for repairs,construction,and <", nonpayment. ch-r.-s or or an other reasona4le cause.lam the owner,or am authorized by the owner of this property top- or he wohich applicatio is made,and I comply with the State Contractors Law 18.27 PERMIT RCW and 29;200, WAC r i - • d U \k.' , IC 0:1) 1)Ccaner/Authoriz-4,,gent Sig,ature Date (Revised 10/12/2.015)