620 112TH ST SE SPACE 17 2024-08-07

WATIF / SEWER UTILITY AP ,ICATION CITY OF EVERETT PERMIT SERVICES EVERETT SUBMITTAL INSTRUCTIONS: Drop off hard copy paper application&plans to 3200 Cedar Street 2nd Floor Intake Drop Box. WASHINGTON CONTACT INFORMATION: (P)425-257-8810 I(E)PermitServices@everettwa.gov I(W)everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: 620 112th St SE, Space 17, Everett, WA 98208 IF APPLICABLE: ❑ OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ISFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑ACCESSORY CHANGE OF USE? M NO 0 YES, FROM TO UTILITY APPLICATION INFORMATION SEWER (check all that apply) WATER (check all that apply) ❑SIDE SEWER REPAIR 0 BACKFLOW PREVENTION(Outside)-Specify device type below: ❑SIDE SEWER ALTERATION ❑RPBA(dom.) ❑DCVA(dom.) ❑DCVA(irr.) ❑DCDA(fire) ❑ NEW SIDE SEWER INSTALLATION 0 WATER LINE BEHIND METER(repair or alteration) ❑ INSTALL BACKWATER VALVE(outside the building) 0 NEW WATER SERVICE INSTALLATION ❑SIDE SEWER CAP-OFF Specify installation type below: ❑SIDE SEWER RECONNECTION 0 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. 0 DOMESTIC: 03/4" 01" 02" ❑Other: ❑I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER 0 IRRIGATION: 03/4" 01" 02" ❑Other: SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER 0 FIRE: 01" 02" 04" 06" 08" ❑Other: SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. ❑ DOMESTIC/FIRE COMBO: 01" 02" ❑Other: CONTACT INFORMATION OWNER NAME: George & Dottie Johnson TENANT BUSINESS NAME(If Commercial): OWNER MAILING ADDRESS: STREET PO Box 12627 CITY Mill Creek STATE WA ZIP 98082 OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: Walker Construction (Brent Walker) CONTRACTOR ADDRESS: STREET 1242 State Ave. , Ste 1, PMB 265 Marysville WA 98270 CITY STATE ZIP CONTRACTOR PHONE: 425.359.7650 CONTRACTOR EMAIL: walkerconstructionbuilder@gmail.com CONTRACTOR LIC.#(REQUIRED): WALKEC*894OA CITY OF EVERETT BUSINESS LIC.#(REQUIRED): '1lele i PRIMARY CONTACT: ❑ OWNER 0 CONTRACTOR In OTHER(Please Specify) Permit Manager CONTACT NAME: CONTACT PHONE: 425.238.6324 Stacy Smith, Smith Land Development CONTACT EMAIL: stacy@stacysmith.net 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 au the owner of ' rop y to perform the work for which application is made,and(comply with the State Contractors Law 18.27 RCW and 296.200A WAC. City of Everett Official Use Only PERMIT# 10.31.2023 I ' et/Authorize ent ' ature Date (Revised 4/21/2022)