1227 KOSSUTH AVE 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: � : � � � �� ] G! !-`-� /�' v� z' 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) ��SIDE SEWER REPAIR ❑ NEW WATER SERV�CE INSTALLATION ❑ SIDE SEWER ALTERATION ❑ COMPLETE SERVICE ❑ METER ONLY E7TIV�VV�TDE SEWER INSTALLATION SERVICE / METER USE: ❑ INSTALL BACKWATER VALVE (autside 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. ❑ IRRIGATIaN: 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: TENANT NAME (If Commercial): OWNER MAILING ADDRESS: sTReer CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: � � � C� CONTRACTOR ADDRESS: srReeT GITY STATE ZIP CONTRACTOR PHONE: CONTRACTOR EMAIL: CONTRACTOR LIC. #(REQUIRED): CITY OF EVERETT BUSWESS LIC. #(REQUIRED): `J � PRIMARY CONTACT: ❑ OWNER ❑ CONTRACTOR ❑ OTHER (Please Specify) CONTACT NAME: CONTACT PHONE: CONTACT EMAIL: AGREEMENT: The undersigned applicant agrees to comply with all provisions of the Evereit Municipal Code Title 14 Water and Sewer or such oiher rules and regulations now exisling or which may be established from time to time. The applicant further agrees, as a condition precedent fo receiving service ihat the utilities division sha/l have the right at any iime, without notice, to shut off or turn on the water supply for repairs, construction, and nonpayment of charges or for any ofher reasonable cause. I am the owner, or 1 am authorized by the owner of this property to perform the work for which application is made, and 1 comply with the State Contractors Law 18.27 RCW and 296.2DpA WAC. , / __ ��-e%t��<�r�`"�'_! ;n -/�/�- il� Owner/Authorized Agent Signature Date City of Everett Official Use Only FEE ., � �.�� PERMIT# U � � ��'�L �'�� (Revised 10/12/2015)