4328 CRESCENT AVE 2025-07-30 - Laserfiche WebLink

WATER / SEWER UTILITY APPLICATION CITY OF EVERETT PERMIT SERVICES EVERETT SUBMITTAL INSTRUCTIONS Drop off hard copy paper app4cabcn&plans to 3200 Gedar Street 2nd Floor ntaxe Drop Pox WASHINGTON CONTACT INFORMATION API 425 257 8810 10 1 PermdServlcesrr@Ieverettwa gov I(W)everettwa gov/permds PROJECT SITE INFORMATION PROJECT ADDRESS pZ�Z J 1 4 yj CC i�le, z IF APPLICABLE ❑OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT tt BUILDING TYPE 4SFR ❑TOWNHOUSE ❑DUPLE!( ❑ADU ❑MULTI FAtIILY Y OF UNiTS ❑C(-)%I 1ERGAL ❑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 IOutside)-Specify device type below ❑SIDE SEWER ALTERATION ❑RPBA(dom) ODCVA(dom) ❑DCVA(irr) ❑DCDA+Frei ,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 6 size below- MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP ❑DOMESTIC 03/4" 5�" 02' ❑Other ❑1 AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑IRRIGATION 03/4" ❑l" 02" ❑Other SERVICES FOR MY MUL TI-FAMILY DEVELOPMENT UNDER ❑FIRE 1:11" ❑2 1:14" 06" ❑8" ❑Other SINGLE OWNERSHIP FILL OUT REVERSE SIDE OF THIS FORM. ❑DOMESTIC/FIRE COMBO ❑l" 02" ❑Other �11 CONTACT INFORMATION OWNER NAME: -e L L TENANT BUSINESS NAME(If Commercial): OWNER MAILING ADDRESS, ;- rrr b l3O ` 7 t S OWNER PHONE: ( t S UI I �(� \D OWNER EMAIL. C V E Ci tt7 CONTRACTORNAME: 41! / i I C ) ~ — L CONTRACTOR ADDRESS- STREFT Q 0 CONTRACTOR PHONE: L-I�-S F raS k( � CONTRACTOR EMAIL. C% - I CL !Jl i .C' CONTRACTOR LIC.#iREQUIRED):G E'N CI CITY OF EVERETT BUSINESS LIC.#(REQUIRED). �aa� PRIMARY CONTACT: ❑OWNER �J CONTRACTOR ❑OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: r' �— S—V V c vl a(,A vt( 6-\L�('( GL 0 J CONTACT EMAIL: a U-•- 4 -1D C 0,, 4 , e AGREEMENT The undersigned applicant agrees to comply with all provisions of the Everett Muni pal Code Tdlo 4 ater and er 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 sorvice 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 1 am authorized by the ow er of this property to perform the work for which application is made,and I comply with the State Contractors Law 16 27 RC and 296 200A WAC City of Everett Official Use Only PERMIT# 3 Z3 �3 U Owner;Au orized Agent Signature Date (Revised 4/21/2022) Ufa �`(- �� 5