1815 BROADWAY 2016-09-13 - Laserfiche WebLink

WATER / SEWER UTILITY APPLICATION 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 PROJ>�C�' S1T� IRIFORM_AT 11®M PROJECT ADDRESS: y UUI,GLWAV IF APPLICABLE: ❑ OUTSIDE CITY LIMITS h BUILDING AREA SF ❑ LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? ❑NO ❑YES, FROM TO tlTILITY APPLIC�ITION INFORMATION SEWER(check all that apply) WATER(check all that apply) ❑ SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION ❑ SIDE SEWER ALTERATION ❑ COMPLETE SERVICE El.METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE I METER USE: ❑ INSTALL 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: 314", 1", 2", OTHER: MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ IRRIGATION: 31411, 111, 2", OTHER: ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑ FIRE: 11, 2", 4", 6", 8", OTHER: SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER ❑ DOMESTIC/FIRE COMBO: 1", 2", OTHER: SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. CONTACT INFORMATION _ OWNER NAME: ' TENANT NAME(if Commercial): OWNER MAILING ADDRESS: STREET crit STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME• v CONTRACTOR ADDRESS: STREET rr//V CITY -Z V-e V'e V l STATE ZIP (i CONTRACTOR PHONE: G 2 -bl2 CONTRACTOR EMAIL: I w��i LI `(. CONTRACTOR LIC.#(REQUIRED)• olla I CITY OF EVERETT BUSINESS LIC. (REQUIRED): PRIMARY CONTACT: ❑OWNER ONTRACTOR ❑OTHER(Please Specify) CONTACT NAME: p CONTACT PHONE: �-iZS� 4O V C'TCONTACT EMAIL: AGREEMENT,The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title City of Everett Official Use Only 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to FEE time_ The applicant further agrees, as a condition precedent to receiving service that the utilities division shall have 40 a[)O the right ata 7 e,without notice,to shut off or turn on the water supply for repairs,construction,and / nonpayme of ch s or for other reasonable cause.I am the owner,or am authorized by the owner of this propertyn.20C. ork foAw "oh application is made,and I comply with the State Contractors Law 18.27 PERMIT RCW an JUOwnerint Si Date (j (Revised 10/12/2015) Il J