4920 24TH AVE W 2023-06-22 - Laserfiche WebLink

ism W ER / SEWER UTILITY APPLICATION EVERETT CITY OFEVERETT ,EVERETTPERMIT ,WA SERVICES 98201 WASHINGTON (P)425-257-8810 I FAX 425-257-8857 I(E)everetteps@everettwa.gov I www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: 4920 24TH AVE. W., EVERETT WA 98203 IF APPLICABLE: ❑OUTSIDE CITY LIMITS © BUILDING AREA3182 SF ©LOT#2 BUILDING TYPE: ©SFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑ACCESSORY, CHANGE OF USE? ❑✓ NO ❑YES, FROM TO UTILITY APPLICATION INFORMATION SEWER(check all that apply) WATER (check all that apply) ❑SIDE SEWER REPAIR [.I NEW WATER SERVICE INSTALLATION ❑SIDE SEWER ALTERATION ❑ OMPLETE SERVICE ©METER ONLY SI SE R I ON' \\ 1(VICE/METER USE: INSTALL BACKWATER VALVE(outside the building) \ ❑✓ SFR ❑SIDE SEWER CAP-QF-F---- ❑MULTI-FAMIL/ #OF UNITS: W SIDE SEW tIRECONNECTION ❑COMMERCIAL MULTIPLE DOMESTIC LATER SERVICES REQUEST WATER SERVICE TYPE/SIZE: (provide calcs to �ort size choice) S�pP ❑I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR .DOMESTIC: 03/4" 01" 02" ❑Other: MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. IRRIGATION: 03/4" 01" 02" ❑Other: ❑I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑FIRE: 01" 02" 04"/6" 1E18" ❑Other: SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER CO DOMESTIC/FIRE COMBO: ©1" 02" ❑Other: SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. ❑BACKFLOW PREVENTION (Outside): ❑RPBA ❑DCDA ❑DCVA CONTACT INFORMATION OWNER NAME: 4900 24th Ave.W., LLC TENANT BUSINESS NAME(If Commercial): OWNER MAILING ADDRESS: STREET526 N. West Ave. #147 crry Arlington STATE WA zIP 98223 OWNER PHONE:360-631-5922 x 3 OWNER EMAIL:officemanager@fullwilerconstruction.com CONTRACTOR NAME:Fuliwiler Construction Inc. CONTRACTOR ADDRESS: STREETsame as above CITY STATE ZIP CONTRACTOR PHONE:same as above CONTRACTOR EMAIL:same as above CONTRACTOR LIC.#(REQUIRED):FULLWCI903M2 CITY OF EVERETT BUSINESS LIC.#(REQUIRED): PRIMARY CONTACT: ❑OWNER ✓❑CONTRACTOR ❑OTHER(Please Specify) CONTACT NAME: CONTACT PHONE:360-631-5922 x 3 /425-344-7803 Mallorie Hefley or Jerry Fullwiler CONTACT EMAIL:officemanager@fullwilerconstruction.com AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to time. The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and nonpayment of charges or for any other reasonable cause.I am the owner,or I am authorized by the owner of this property to perform the work for which application is made,and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. City of Everett Official Use Only PERMIT# " C(-( ao a t/te''' \45)- (P/1 3/2° U 11 � I o Owner/Authorized Agent Signature • Date (Revised 10/12/2018)