3501 HOYT AVE 2016-08-24 - Laserfiche WebLink

� � �ER / SEWER UiILITY �L.ICATION CITY 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 PROJECT SITE INFORMATION PROJECT ADDRESS: �1 IF APPLICABLE: ❑ OUTSIDE CITY LIM S ❑ BUILDING AREA SF ❑ LOT # BUILDING TYPE: ❑SFR-DETACHED ❑5FR-ATTACHED ❑DULEX ❑MULTI-FAMILY� OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? � N� ❑ YES, FROM TO UTILITY APPLICATION INFORMATION SEWER (check all that apply) WATER (check all that apply) ❑ SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION ❑ SIDE SEWER ALTERATION ❑ COMPLETE SERVICE ❑ METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE / METER USE: �INSTALL BACKWATER VALVE outside the building) ❑ SFR ❑ SIDE SEWER CAP-OFF ❑ MULTI-FAMILY -# OF UNITS: ❑ SIDE SEWER RECONNECTION ❑ COMMERCIAL MULTfPLE 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. ❑ IRRIGATION: 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 ❑ DOMESTIC/FIRE COMBO: 1", 2", OTHER: SINGLE OWNERSHIP. F/LL OUT REVERSE SIDE OF THIS FORM. CONTACT INFORMATION OWNER NAME: TENANT NAME (If Commercial): OWNER MAILING ADDRESS: sTREET L� �� CIlY �/� � STATE � • ZIP � �� OWNER PHONE: OWNER EMAIL: . . . . �\ � r -6 _ ' CONTRACTOR NAME: j ! CONTRACTOR ADDRESS: V sTReeT ? � % CITY � �j� STATE �/�� P�� ZIP � � ; ,� [ "�. CONTRACTOR PHONE: �'� �� j� CONTRACTOR EMAIL: CONTRACTOR LIC. #(REQUIRED): � �, ,�j � t"j� �G? CITY OF EVERETT BUSINESS LIC. #(REQUIRED): % � � `�7'""J PRIMARY CONTACT: ❑ OWNER �CONTRACTOR ❑ OTHER (Please Specify) CONTACT NAME: CONTACT PHONE: .- �%� `�1 . ,� i �-� �i' i -i � � � -'`-� �`j�� i/� �� Ey � � CONTACT EMAIL: AGREEMENT.' The undersigned applicant agrees to compiy with all provisions of the Everett Municipal Code Tifle 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to time. The a licant further agrees, a con on precedent to receiving service that the utilities division shall have the ri af an t' without no ' e, to shut o or iurn on the water supply for repairs, construction, and no ayment o har s ny other reas nable cause. I am the owner, or l am authorized by the owner of this operty to pe m e work or which applrc tion is made, and I comply with the State Contractors Law 18.27 CW and 296. A AC. ,� �, , ,,, � / Owner/AutFXori�kd�qent5i�atkre\ � / ' Date City of Everett Official Use Only FEE ;^� � Cf % � PERMIT # U � I �/ �/ G� (Revised 10/92/2015)