802 CROWN DR 2016-05-19 - Laserfiche WebLink

417-7- WATER / SEWER UTILITY APPLICATION CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P)425-257-8810 I FAX 425-257-8857 I (E) everetteps@everettwa.gov I www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: R.:12_ C R te'�.] C)6 , 12e- IF APPLICABLE: ❑ OUTSIDE CITY LIMITS BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-CpETACHED 21-SFR-ATTACHED ODULEX ❑MULTI-FAMILY-#OF UNITS: OCOMMERCIAL ❑INDUSTRIAL CHANGE OF USE? LO ❑YES, FROM TO UTILITY APPLICATION INFORMATION SEWER(check all that apply) WATER(check all that apply) ❑ SID SEWER REPAIR ❑ NE • WATER SERVICE INSTALLATION IDE SEWER ALTERATION ❑ CO 'LETE SERVICE 0 METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/M:TER USE: El INSTALL BACKWATER VALVE(outside the building) El SFR ❑ SIDE SEWER CAP-OFF ❑ MULTI-FAMILY-# o UNITS: ❑ SIDE SEWER RECONNECTION ❑ COMMERCIAL MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE: cle 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", 0 'HER: SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. CONTACT INFORMATION OWNER NAME: (�.0u\.t(,(} kkt O C TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET so a C(C)kJ k.) - CITY `�� / STATE LA/p., ZIP 9e2OJ OWNER PHONE: / OWNER EMAIL: , / NG,_/ � �Z rr�� /n� //�is�'S 5 �G LLL CONTRACTOR NAME: �t/C/7 / 1u/ u � / LJj) to LP 1, CONTRACTOR ADDRESS: STREET f G. i,JC S S 7 3 CITY SiyerZ L ,- J STATE ZIP C7e CONTRACTOR PHONE:CO n13 I 5ci�9 CONTRACTOR EMAIL: iSP „g--e Q CONTRACTOR LIC.#(REQUIRED): 011 a6 P� BUSINESS CITY OF EVERETT LIC.#(REQUIRED): 5-37 8r-2-- C� PRIMARY CONTACT: ❑ OWNER CONTRACTOR ❑ OTHER(Please Specify) CONTACT ✓NAME: `/ 7 CONTACT PHONE: �06 Qi3 I �Cj ) PFA , CEJ9 CONTACT EMAIL: �1f �1L �Y �U` G✓ /�� CC�`�I 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 ._ O en the right at any time,without notice, to shut off or turn on the water supply for repairs,construction,and nonpayment of charges or foraable cause.I am the owner,ort am authorized by the owner of this property to pe eriefer-which application is m..- - d I comply with the State Contractors Law 18.27 PERMIT# RCW and 296.200 Owner/Authorized Agent Signature Date (Revised 10/12/2015)