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WA7*R / SEWER UTILITY AI&LICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> (P) 425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: 4411 29th Dr. SE, Everett, WA <br /> IF APPLICABLE: 1:1 OUTSIDE CITY LIMITS El BUILDING AREA 1-,910 SF ❑ LOT# 121 <br /> BUILDING TYPE: ®SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL <br /> CHANGE OF USE? ❑ NO ❑ YES, FROM TO <br /> UTILITY APPLICATION INFORMATION <br /> SEWER(check all that apply) WATER (check all that apply) <br /> ❑ SIDE SEWER REPAIR IN NEW WATER SERVICE INSTALLATION <br /> ❑ SIDE SEWER ALTERATION ❑ COMPLETE SERVICE ❑ METER ONLY <br /> ® NEW SIDE SEWER INSTALLATION SERVICE/METER USE: <br /> ❑ INSTALL BACKWATER VALVE(outside the building) ❑ SFR <br /> ❑ SIDE SEWER CAP-OFF ❑ MULTI-FAMILY-#OF UNITS: <br /> ❑ SIDE SEWER RECONNECTION ❑ COMMERCIAL <br /> MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE: (circle desired size) <br /> ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR IN DOMESTIC: 3/4", 1", 2", OTHER: <br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ IRRIGATION: 3/4", 1", 2", OTHER: <br /> ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑ FIRE: 1", 2", 4", 6", 8", OTHER: <br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER ❑ DOMESTIC/FIRE COMBO: 1", 2", OTHER: <br /> SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. <br /> CONTACT INFORMATION <br /> OWNER NAME: Polygon WLH, LLC TENANT NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET 11624 SE 5th Street, Suite 100 <br /> Bellevue CITY WA STATE 98005 ZAP <br /> OWNER PHONE: 425.586.7700 OWNER EMAIL: alan.panl@polygonhomes.Com <br /> CONTRACTOR NAME: Same as Owner <br /> CONTRACTOR ADDRESS: STREET <br /> CITY STATE ZIP <br /> CONTRACTOR PHONE: 425.586.7700 CONTRACTOR EMAIL: aIan.pani@polygonhomes.com <br /> CONTRACTOR LIC.#(REQUIRED): polygwl863pW CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 053222 <br /> PRIMARY CONTACT: 12 OWNER ❑ CONTRACTOR ❑ OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: 425.586.7700 <br /> Alan Pani CONTACT EMAIL: alan.panl@polygonhomeS.Com <br /> AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title City of Everett Official Use Only <br /> 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to FEE <br /> time. The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have <br /> the right at any time, without notice,to shut off or turn on the water supply for repairs,construction, and <br /> nonpayment of charges or for any other reasonable cause.I am the owner,or I am authorized by the owner of this <br /> property to perform the work for which application is made,and 1 comply with the State Contractors Law 18.27 E6U <br /> RMIT# <br /> RCW and 296.200A WAC. <br /> t�t.C,C I ,, <br /> n, �_ Pani, 08/04/16 <br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015) <br />