1132 RUCKER AVE 2024-07-05 - Laserfiche WebLink

WATER 1 SEWER UTILITY APPLICATION CITY OF EVERETT PERMIT SERVICES EVERETT SUBMITTAL INSTRUCTIONS: Drop oft hard copy paper applicatlon&plans to 3200 Cedar Street 2nd Floor Intake Drop Box, WASHINGTON CONTACT INFORMATION:(P)425,257,8810 1(E)Perm'stServices@everettwa.gov I(W)everettwa.govlpermits PROJECT SITE INFORMATION ' y� PROJECT ADDRESS: UG�Y/ flue, 6V eft� � vV/ A � U IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT# BUILDING TYPE: ❑SFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY4 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 ❑BACKFLOW PREVENTION(Outside)-Specify device type below: ❑SIDE SEWER ALTERATION ❑RPBA(dom.) ❑DCVA(dom.) ❑DCVA(irr.) ❑DCDA(fire) ❑NEW SIDE SEWER INSTALLATION ❑WATER LINE BEHIND METER(repair or alteration) ❑ INSTALL BACKWATER VALVE(outside the building) ❑NEW WATER SERVICE INSTALLATION ❑SIDE SEWER CAP-OFF Specify installation type below: ❑SIDE SEWER RECONNECTION ❑NEW COMPLETE SERVICE MULTIPLE DOMESTIC WATER SERVICES REQUEST ❑METER ONLY ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR Specify water service type&size below: MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ DOMESTIC: 0314" ❑1" ❑2" ❑Other: ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER IRRIGATION: L1 314,, ❑1" 112" ❑Other: SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER ❑ FIRE: ❑1" 112" ❑4" 116" ❑8" ❑Other: SINGLE OWNERSHIP.FILL OUT REVERSE SIDE OF THIS FORM. ❑ DOMESTICIFIRE COMBO: ❑1" 112" ❑Other CONTACT INFORMATION OWNER NAME: \W �G,r�\ l/ TENANT BUSINESS NAME(If Commercial): OWNER MAILING ADDRESS: s71111 11,351 CITY 1f I( f n�, STATE LJ 21P V OWNER PHONE: S` j tJ` '31-1 OWJNER EMAIL: 9 �Y� J CD W)CC L� CONTRACTOR NAME: Co VY1J C� 7' Choc �e-' ti �� i CONTRACTOR ADDRESS: s....T O r/�- t L\ A✓-e J ] CITY ( � STATE� V 1(�/r" ZiP v 'i t( CONTRACTOR PHONE: �� S`S L 1 31�y CONTRACTOR EMAIL: Clr�� f �IJ 4!P- ��, Ner +fit e_<?KCiJ CONTRACTOR LIC.#(REQUIRED):COKA jOg CITY OF EVERETT BUSINESS LIC.#(REQUIRED): PRIMARY CONTACT: ❑OWNER [CONTRACTOR ❑OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: L"\ 0"\ CONTACT EMAIL: 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,wlthout notice,to shut of turn on the water supply for repairs,construction,and nonpayment of charges or for any other reasonable cause.1 am the owner,or f am authorized by the ovner of thh- party to perform the work for which application is made,and 1 comply with the State Contractors Law 18.27 RCW and 296.200A WAC. / City of Everett Official Use Only PERMIT# of do) IU 2�v2- nS1 OwnerlAutNoriz d AgehT Ignature Date (Revised 8/4/2021)