816 OLYMPIC BLVD 2017-01-13 - Laserfiche WebLink

VVAT'ER / SEWER IJiILiiY APPL.ICATION 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: � 4 IF APPLICABLE: ❑ OUTSIDE CITY LIMI S ❑ 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 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: TENANT NAME (If Commercial): OWNER MAILING ADDRESS: srReer CITY STATE ZIP WNER PHONE: OWNER EMAIL: CONTRACTOR NAME: � (� CONTRACTOR ADDRESS: EEr � 1 C �� • � 1 � c� d CITY • STATE ZIP CONTRACTOR PHONE: CONTRACTOR EMAIL: CONTRACTOR LIC. #(REQUIRED): GTY OF EVERETT BUSINESS LIC. #(REQUIRED): � PRIMARY CONTACT: ❑ OWNER ❑ CONTRACTOR ❑ OTHER (Please Specify) CONTACT NAME: CONTACT PHONE: CONTACT EMAIL: AGREEMENT: The undersigned applicani agrees to comply with all provisions of the Everett Municipal Code Title 94 Water and Sewer or such other rules and regulations now exisfing or which may be established from time to time. The applicanf further agrees, as a condition precedent fo receiving service that the utilities division shall have the rrght at any time, without notice, to shuf off or turn on the water supply for repairs, consfruction, and nonpayment of charges or for any other reasonab/e cause. I am the owner, or l am authorized by the owner of this property�toxye�form the work for which�ic�,tion is made, and I comply witii the State Contractors Law 18.27 �if� Agent Signature � 1 Date City of Everett Officia! Use On/y FEE r� ��,�� ✓ PERMI� # � U I % I � // `u (Revised 10/12/2015)