10709 9TH DR SE 2017-08-02 - Laserfiche WebLink

11v rER / 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: � Q � � 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 '�1 YES, FROM Z- � TO � UTILITY /�PPLICATION 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: sTREeT � �� — r �� CITY � STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: ZQ� CONTRACTOR ADDRESS: s�nzeer CITY STATE ZIP CONTRACTOR PHONE: � I � CONTRACTOR EMAIL: (Ih.� t-(,�j� ,C�ff"`� CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LI .#(REG2UIRED): PRIMARY CONTACT: ❑OWNER ❑ CONTRACTOR ❑OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: CONTACT EMAIL: AGREEMENT.•The undersigned applicant agrees to comp/y wiih all provisions of the Everett Municipal Code Title City of Everett Officia/Use Only 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to FEE fime. The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have the right at any time,witho t notice,to shut off or turn on the water supply for repairs,construction,and nonpayment of charges o for a y other reasonable cause.1 am the owner,or I am authorized by the owner of this property to perfo �k f which application is made,and 1 comply wiih the State Contractors Law 18.27 PERM IT# RCW and 296. � � ��^ O 7- Owner/Au iz A ent Signature Date (Revised 10/92/2015)