2309 ROCKEFELLER AVE 2016-08-12 - Laserfiche WebLink

. ��, �� I�� i��f�� C1TY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P} 425-257-8810 � FAX 425-257-8857 �(E) everetteps@everettwa.gov � www.everettwa.gov/permits UTILITY APPLICATIOI� INFORMATIOW SEWER (check all that apply) WATER (check all that apply) ❑ SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION ❑ SIDE SEWER ALTERAT[ON ❑ COMPLETE SERVICE ❑ METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE / METER USE: 1STALL BACKWATER VALVE (outside the building) ❑ SFR ❑ SIDE SEWER CAP-OFF ❑ MULTI-FAMILY -# OF UNITS: ❑ SIDE SEWER RECONNECTION ❑ COMMERCIAL MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE / SIZE: (circle desired size) ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR ❑ DOMESTIC: 3/4", 1", 2", OTHER: MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑�RRIGATION: 3/4", 1", 2", OTHER: ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑ FIRE: 1", 2", 4", 6", 8", OTHER: SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER ❑ DOMESTICIFIRE COMBO: 1", 2", OTHER: SINGLE OWNERSHIP. F/LL OUT REVERSE SIDE OF THIS FORM. OWNER NAME: �_ �, OWNER MAfLING ADDRESS OWNER PHONE: CONTRACTOR NAME: � CONTRACTOR ADDRESS; CONTACT INFORMATION STREET �� CITY 7 �J� STREET �� ' � TENANT NAME (If Com OWNER EMAIL: 24.1 " �- ' 'U Q .S'��a STATE CITY STATE ��/ � CONTRACTOR PHONE: L Z�" ��('d � Z—� GONTRACTOR EMAIL: L W✓� � G CONTRACTOR LIC. #(REQUIRED): • Q%�/�I� CITY OF EVERETT BUSINESS LIC. #(REQL PRIMARY CONTACT: ❑ OWNER ONTRACTOR ❑ OTHER (Please Specify) ICON CT NAME: CONTACT PHONE: � 2 j ---� 2 U ��\ � , CONTACT EMAIL: �C� 1 V �( • ��,t J ZIP ZIP � AGREEMENT: The undersigned applicani agrees fo comply with all provisions of the Everett Munrcipal Code Tit/e City of Everett Official Use Only 94 Water and Sewer or sucfr ofher iules and regulations now exisfing or which may be established from fime to FEE k�%i time. The applicant further agrees, as a condition precedenf to receiving service that the utilities drvision sha!l have ,�j� �� v the right at a ', ithout notice, to shut off or turn on the water supp/y for repairs, consf�uction, and �� / nonpay of charge or for any other reasonab/e cause. I am the owner or I am authorized by the owner of this I properf to p m the rk for which application is made, and I comply with the Stafe Contractors Law 1827 PERMIT # RCW d 296 0 A �7.� �: � (� . lJ � Z nature Date (Revised 90/12/2015)