1818 MCDOUGALL AVE 2016-10-03 - Laserfiche WebLink

WATER I SEWER UTILITY APPLICATION CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT,WA 98201 (P) 425-257-8810 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits PIZOACT SITE INFORIWAT16N PROJECT ADDRESS: IF APPLICABLE: ❑OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? ❑NO ❑YES, FROM TO UTILITY p1PPLICAT.ION INFORIIIIATION _. ._ 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: L 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: 3/4", 1", 2", OTHER: ❑ 1 AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑ FIRE: V, 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 CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: Ij 19 CONTRACTOR ADDRESS: STREETM6 VI V o(,V/W r f� STATE ZP CITY v CONTRACTOR PHONE: IGONTRACTOR EMAIL: ��w!�i e I CONTRACTOR LIC.#(REQUIRED) _ (,� /� CITY OF EVERETT BUSINESS LIC, (REQUIRED): bS PRIMARY CONTACT:^ '❑OWNER MONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: CONTACT EMAIL: AGREEMENT.-The undersigned applicant agrees to comply with all provisions of the Evera Municipal Code Title City of Evereft Official Use Only 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to FEE Q V time_ The applicant further agrees, as a condition precedent to receiving service that the utilities division shall have V the right at arXTINP,without notice,to shut off or turn on the water supply for repairs,construction,and O nonpayme of ch nworkr herreasonable cause.1 am the owner,orl am authorized by the owner of this properly t perf m h applicationis made,and 1 comply with the State Contractors Law 18.27RCWan 29 .200 J� ev q � I (} Owner/Au ri ent Si Date (�' (Revised 10/12/2015) v