221 SKYLINE DR 2017-04-11 - Laserfiche WebLink

W, 'ER / SEWER UTILITY AiPLICATION LICAT'I®N CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P)425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: 11/1 S IF APPLICABLE: ❑ OUTSIDE CITY L MITS ❑ BUILDING AREA SF ❑ LOT# BUILDING TYPE: ❑SFR-DETACHED E]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: )I 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: STREET CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: t� CONTRACTOR ADDRESS: STREET V CITY PVffVr+ STATE V` • ZIP CONTRACTOR PHONE: Ljj CO TRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): AA CITY OF EVERETT BUSINESS LIC.#(REQUIRED): O PRIMARY CONTACT: ❑OWNER ❑ CONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: I,(� }/�g ✓�1 Y�,''�/,� CONTACT EMAIL: 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 maybe established from time to FEE time.The applicant further agrees, a con precedent to receiving service that the utilities division shall have the right at any ' e,w" t notic ,to shut off o turn on the water supply for repairs,construction, and _ nonpayment f ch r awo r or an other reasona le cause.I am the owner,or I am authorized by the owner of this property to p or hich applicatio is made,and I comply with the State ontractors Law 18.27 PERMIT#RCW and 29 200 caner/Authoriz gent Sig ature Date (Revised 10/1212015)