6120 LOMBARD AVE 2025-02-28 - Laserfiche WebLink

WATER / SEWER UTILITY APPLICATION 1 i CITY OF EVERETT PERMIT SERVICES E V E R E T T 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 1(E)PermitServices@everettwa.gov I(W)everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: cjV E 6? e .� IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT# BUILDING TYPE: SFR ❑TOWNHOUSE ❑DUPLEX ❑ADU []MULTI-FAMILY•#OF UNITS: ❑COMMERCIAL ❑ACCESSORY CHANGE OF USE? *0 ❑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(fire) ❑NEW SIDE SEWER INSTALLATION �IWATER 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: 113/4" 01" 112" ❑Other: ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER IRRIGATION: 113/4" 111" 112" ❑Other SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER ❑FIRE: ❑1" ❑2" ❑4" ❑6" ❑8" ❑Other: SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. ❑DOMESTIC/FIRE COMBO: 01" 112" ❑Other: CONTACT INFORMATION OWNER NAME: /2 TENANT BUSINESS NAME(If Commercial): OWNER MAILING ADDRESS: STREET Let v d!/t° CIT/Y / jA& STATE ZIP OWNER PHONE: `3 t� 766 OWNER EMAIL: Q'Q't'Q d GQf •,7'Q CONTRACTOR NAME: S .07 %trr �C ass CONTRACTOR ADDRESS: STREET 14 ©e 7k S-1 tte f ttJ CITY 1 'e 0 STATE ��'L ZIP CONTRACTOR PHONE: 206- y CONTRACTOR E AI . GE t, I EI 7 6 7/v,�'-7— CONTRACTOR LIC.#(REQUIRED) CITY OF EVERETT BU NES LIC.#(REQUIRED): PRIMARY CONTACT: ❑OWNER ❑ CONTRACTOR OTHER(Please Specify) f CONTACT NAME: CONTACT PHONE: (`—�� 1 CC CONTACT EMAIL:Lr 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 f thl perty to perform the ork 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# Ow r uthorized gent Signature ate Z (Revised 1412021)