5409 HIGHLAND RD 2017-01-13 - Laserfiche WebLink

,ti VI�'ER / SEWER UTILITY�'PLICATION 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: S^y� �f ��' /n 1f HG• � �D 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 APPLICATION INFORMATION SEWER (check all that apply) 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. OWNER NAME: OWNER MAILING ADDRESS: OWNER PHONE: NTRACTOR NAME: NTRACTOR ADDRESS � STREET S ciTv CONTACT INFORMATION Ss� � c/ TENANT NAME (If Commerciai): '�� /�`��r� 1�� I� 1s I/�i/i'Ti�� STATE l't��- OWNER EMAIL: �'4 /TI�C�I�C� f��li:y,�n STREET Z C� � J� �"�7s'P L c�rr ��'�"��— STATE NTRACTOR PHONE: Y�' 77� Z?�� CONTRACTOR EMAIL: CONTRACTOR LIC. #IREQUI PRIMARY CONTACT: ❑ OWNER CO�T NAME: OF EVERETT BUSINESS LIC R ❑ OTHER (Please Specify) _ CONTACT PHONE: ��S _��j� ��/'�� GUN I AG I tMAIL: AGREEMEN : The undersig ed applicant agrees to comply with all provisions of the Everett Municipal Code Title 14 Water a Sewer or such other rules and regulations now existing or which may be established from trme to time. The applicant further agrees, as a condition precedent to receiving service fhat the utilities division shall have the right af any time, without notice, to shut off or turn on the water supply for repairs, construction, and nonpayment of charges or for an !+,�:-;=�ea�b/e cause. I am the owner, or 1 arn authorired by the owner of this property to perform the w or whic plication is made, and I comply with the State Contractors Law 18.27 RCW and 296.200A AC. �' n _�� /� (,,. Owner/Autj%rized Agent Signature Date - ZZ � ziP /� � Z c� ZIP City of Everett Official Use Only FEE � � � � ��, � PERMIT # U �- � (Revised 10/17J2095)