1726 ROCKEFELLER AVE 2016-10-21 - Laserfiche WebLink

WATER / SOWER 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 PIZ®JEC`d' SITE INFORMA776N PROJECT ADDRESS: D >C IF APPLICABLE: ❑OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ElLOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? ❑NO ❑YES, FROM TO LDTiLITY APPLICATION INFORMATION' SEWER(check all that apply) WATER(check all that apply) ❑ SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION ❑ SIDE SEWER ALTERATION ❑ COMPLETE SERVICE ET METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: l INSTALL BACKWATER VALVE(outside the building) El SFR ❑ SIDE SEWER CAP-OFF ❑ MULTI-FAMILY-#OF UNITS: ❑ SIDE SEWER RECONNECTION ❑ COMMERCIAL MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE I 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: 3/411, t", 2", OTHER: ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑ FIRE: V% 2", 4", 6", 8", OTHER: SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER ❑ DOMESTIC/FIRE COMBO: V, 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: // 1 � 1 U A/ CONTRACTOR ADDRESS: STREETC1? /I V ( aV 1A A"-" CITY e v`� STATE ZJP V (i U CONTRACTOR PHONE: 2 -bl2 S /CONTRACTOR EMAIL: v V-0�r11� y `I CONTRACTOR LIC.#(REQUIRED): P1 tr) L)�/ CITY OF EVERETT BUSINESS LIC. (REQUIRED): b 5 PRIMARY CONTACT: ❑+OWNER ONTRACTOR ❑OTHER(Please Specify) CONTACT NAME: n CONTACT PHONE: V Ivy, C,T VK_0_ - CONTACT EMAIL: AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title City of Everett Official Use Only 94 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 the right at a e,without notice,to shut off or turn on the watersupply for repairs,construction,and O/D� nonpayme of ch s or for otherreasonable cause.I am the owner,or I am authorized by the owner of this , i� property t pert m work for w .ch application is made,and I comply with the State Contractors Law 98.27 PERMIT# RCW an 29 .200 C. J� U � I o//1—O 2D Owner/Au ri ent Si Date (Revised 90/9212095)