4321 30TH DR SE 2017-09-11 - Laserfiche WebLink

WADER / SEWER UTILITY 40PLICATION 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 ( www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: 4321 30th Dr. SE, Everett, WA 98203 IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDING AREA 9 SF ❑ LOT# 159 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 IN 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: 01 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: Polygon WLH, LLC TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET 11624 SE 5th Street, Suite 100 Bellevue CITY WA STATE 98005 ZIP OWNER PHONE: 425.586.7700 OWNER EMAIL: alan.panl@polygonhomes.com CONTRACTOR NAME: Same as Owner CONTRACTOR ADDRESS: STREET CITY STATE ZIP CONTRACTOR PHONE: 425.586.7700 CONTRACTOR EMAIL: alan,pani@polygonhomes.com CONTRACTOR LIC.#(REQUIRED): polygwl863pW ICITY OF EVERETT BUSINESS LIC.#(REQUIRED): 053222 PRIMARY CONTACT: N OWNER ❑ CONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: 425.586.7700 Alan Pani CONTACT EMAIL: alan.panl@polygonhomes.com 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 may be established from time to FEE time. The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have10 the right at any time, without notice,to shut off or turn on the water supply for repairs,construction, and O (��O 0 nonpayment of charges or for any other reasonable cause. I am the owner,or I 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 PERMIT# RCW and 296.200A WAC. l�tI Xan, �_ Pap-t, 08/18/16 a— ©cpo Owner/Authorized Agent Signature Date (Revised 10/12/2015)