1015 100TH ST SW 2024-08-06 - Laserfiche WebLink

WATER I SEWER UTILITY APPLICATION 0_4 �� CITY OF EVERETT PERMIT SERVICES EVERETT 3200 CEDAR STREET,EVERETT,WA 98201 WASHINGTON (P)425-257-8810 1 FAX 425-257-8857 1(E)everetteps@everettwa.gov I WWN.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: ��5 �S +�-�/' (4) 1IF APPLICABLE: ALI OUTSIDE CITY LIMITS V. BUILDING AREA BUILDING TYPE: DISFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL DACCESSORY CHANGE OF USE? 19NO ❑YES, FROM TO UTILITY APPLICATION-INFORMATION SEWER(check all that apply) WATER(check all that apply) ❑SIDE SEWER REPAIR KNEW WATER SERVICE INSTALLATION ❑SIDE SEWER ALTERATION KCOMPLETE SERVICE ❑METER ONLY ❑NEW SIDE SEWER INSTALLATION SERVICE/METER USE: ❑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:(provide caics to support size choice) ❑i AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR DOMESTIC: N3/4" 01" ❑2" ❑Other: MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑IRRIGATION: ❑3/4" 01" 02" ❑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: ❑l" ❑2" ❑Other: SINGLE OWNERSHIP.FILL OUT REVERSE SIDE OF THIS FORM. ❑BACKFLOW PREVENTION(Outside): ❑RPBA ❑DCDA ❑DCVA CONTACT INFORMATION OWNER NAME: .BU v MgA C OWSr 1A1 If• TENANT BUSINESS NAME(If Commercial OWNER MAILING ADDRESS: STREET O k '49 '_�11/,4`, CITY STATE U/. ZIP t� OWNER PHONE: �� G' S~S� OWNER EMAIL: 8U !W,( 60_5 T-0S/WC N 0, 67"-01_,Z �L CONTRACTOR NAME: -Sd Al L 41S -Ado IZE CONTRACTOR ADDRESS: STREET CITY STATE ZIP CONTRACTOR PHONE: CONTRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): V SiC ' C C' CITY OF EVERETT BUSINESS LIC.#(REQUIRED): PRIMARY CONTACT: OWNER NCCONTRACTOR ❑OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: — &276- 6-5-LI P/)04 )49U 5 /fes CONTACT EMAIL U' CUSS L'O S t)C-7 C W 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 tum on the water supply for repairs,construction,and nonpayment of charges or for any other reasonable cause.I am the owner,or t em outhonzetl by the owner or trite property to perform the work for-w h eppli-11o.is made,and I comply with the State Contractors Lew 1&.27 RCW and 286.200A WAC. City of Everett Official Use Only PERMIT# 1 2_1 o6 - o3L Owner/Authorized Agent Signature Date (Revised 10/12/2018)