3105 44TH ST SE 2017-09-19 - Laserfiche WebLink

W6rER / SEWER UTILITY 6'PLICATION 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: 3105 44th St. SE, Everett, WA 98201 IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDING AREA 4_97t SF ❑ LOT#_1 68 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 IN 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: Polygon WLH, LLC TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET 11624 SE 5th Street, Suite 100 Bellevue clry 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 CITY 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 r 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 have O m( o i / the right at any time, without notice, to shut off or turn on the water supply for repairs, construction, and 4 � ►YnG ✓ nonpayment of charges or for any other reasonable cause. I am the owner,or 1 am authorized by the owner of this property to perform the work for which application is made,and l comply with the State Contractors Law 18.27 PERMIT# RCW and 296.200A WAC. ,n I 0'&'M �_ panI . 07/06/16 U t� ` DJ Owner/Authorized Agent Signature Date (Revised 10/1212015)