6708 MORGAN RD 2017-01-13 - 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 PROJECT SITE INFORMATION PROJECT ADDRESS: � ��„ ��,�1 � IF APPLICABLE: ❑ OUTSIDE CITY LI TS ❑ 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 APPLICATION INFORMATION SEWER (check all that appiy) WATER (check all that apply) IDE 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 MULTIPLE 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. FILL OUT REVERSE SIDE OF THIS FORM. CONTACT INFORMATION OWNER NAME: '� i TENANT NAME (If Commercial): �� e r� �.� _5-�- OWNER MAILING ADDR SS: sTREET � ��n �➢�. r STATE ,�E� Z�P r��, OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: � i `�'^ CONTRACTOR ADDRESS: sTReeT �,r'.,� 1 �)� i,E: � .�-./I, C� �^ � �'Ol'7 Ci �� 'I CITY �� i1 �� STATE ��" L� ZIP �� CONTRACTOR PHONE: CONTRACTOR EMAIL: CONTRACTOR LIC. #(REQUIRED): LO � C l � L� � CITY OF EVERETT BUSINESS LIC. #(REQUIRED): �� '" PRIMARY CONTACT: ❑ OWNER ONTRACTOR ❑ OTHER (Please Specify) CONTACT NAME: CONTACT PHONE: � � � � �7 � �;� ��rC �--�V.� CONTACT EMAIL: AGREEMENT: The undersigned applicant agrees to comply with all provisions of the Everelt Municipal Code Title 14 Water and Sewer or such other rules and regulations now exisfing or which may be established from time to time. The applicant further agrees, as a condition precedent to receiving service that the utilities division shall have the right at any time, without notice, to shut off or furn on the wafer supply for repairs, construction, and nonpayment of charges or for any other reasonable cause. 1 am the owner, or I am authorized by the owner of this property io perform the work for which application is made, and I comply with the State Contractors Law 18.27 RCW 96.200 �� _ v �i� ;' �" �-v � ��(.;� er/Authorized Agent Signature Date City of Everett Official Use Only FEE � `� PERMIT # U �� , (Revised 10/12/2015)