4411 FEDERAL AVE 2024-07-01 - Laserfiche WebLink

WATER / SEWER UTILITY APPLICATION CITY OF EVERETT PERMIT SERVICES EV E R E T T SUBMITTAL INSTRUCTIONS Drop off hard copy paper appl,cMion 3 plans to 3200 Cedar Street 2nd Floor IrtakP(imp&)x WASHINGTON CONTACT INFORMATION 1,P)425 257 8810 1 IEI Permit Service s@evereitwa gov((W)everettwa govperm,ts PROJECT SITE INFORMATION PROJECT ADDRESS -li--� 11 F,, Civ c,- ' � e `L l% -LN (,j0 L IF APPLICABLE ❑OUTSIDE CITY LIMITS Cl BUILDING AREA SF ❑l OT# BUILDING TYPE SFR ❑TOWNHOUSE ❑DUPL FX ❑ADU ❑MULTI FAMILY-#OF UNITS []COMMERCIAL ❑ACC F CHANGE OF USE7 ❑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(dour) ❑DCVA(irr) ❑DCDA rfun, a:NEW SIDE SEWER INSTALLATION ❑WATER LINE BEHIND METER(repair or alteration) ❑INSTALL BACKWATER VALVE(outside the building) O 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 1:11 AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR Specify water service type B size below- MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP ❑DOMESTIC 03/4 ,41 02" ❑Other ❑1 AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑IRRIGATION ❑3%4 ❑t' 1:12- ❑Other SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER ❑FIRE Or 02' 04 06" ❑8' ❑Other SINGLE OWNERSHIP FILL OUT REVERSE SIDE OF THIS FORM. ❑DOMESTIC/FIRE COMBO ❑1" 02" ❑Other A 1/ CONTACT INFORMATION OWNER NAME: M A V-t 3 / TENANT BUSINESS NAME(If Commercial): OWNER MAILING ADDRESS: It 3 ,? - r-i-- c" L L L S fit—C V�S S-ATE (,,� OWNER PHONE: L4 Z� S`z' �-(_ ( OWNER EMAIL: :Zi;-LZ_ j CEJ C CONTRACTOR NAME: CONTRACTOR ADDRESS: "REE f7ii Lst STATE CONTRACTOR PHONE: L�» zh,�t(G� CONTRACTOR EMAIL Cv1/4- L : ti r i (/,-D r+„ CONTRACTOR LIC.#rREOUIRED)• CITY O EVERETT BUSINESS LIC.41REOUIRED, PRIMARY CONTACT: ❑OWNER ONTRACTOR ❑OTHER(Please Specify) CONTACT NAME:/ CONTACT PHONE: CONTACT EMAIL (iyl/�� C '•l/ C ti t L I'� AGREEMENT The undersgned apphcon agrees to comply with oil provisions of the Everett Mun tpal Code TX61�4kVater and wer or such other rulos and regulations now existing or which may be estobhshed 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 lum on the water supply for repairs,construction,and nonpayment or charges or for any other reasonable cause I am the owner.or I am authonzed by the owner of this property to perform the work for which application,s made,and I comply with the State Contractors Law f8 27 RCW and 296 200A WAC City of Everett Official Use Only 7LT # � _ 3 Owner/Authorized Agent Signature Date (Revised 4121/2022) --oaf