780 CROWN DR 2017-10-18 - Laserfiche WebLink

WMER / SEWER UTILITY 4#PLICAT1®N CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P)425-257-8810 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: 71K0 IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT# BUILDING TYPE: XFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? �O El 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: ❑ 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: Ell 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. L CONTACT INFORMATION OWNER NAME: ?al TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET /�, `J Z CITY �ci'G STATE kJr` ZIP '9D Z� J OWNER PHONE: OWNER EMAIL: CONTRACTORNAME: CONTRACTOR ADDRESS: STREET Z�tU l 5k3e1 CITY �� STATE W� ZIP oLV(O CONTRACTOR PHONE: ZOro-43Z ��1�I CONTRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): 50 VT1ALop 0-11 G(o CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 0391010 PRIMARY CONTACT: ❑OWNER MCONTRACTOR ❑OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: Zo(v •qc, q Lt.ye6U 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 may be established from time to FEE time. The applicant further agrees, as a condition precedent to receiv" g service that the utilities division shall have / the right at any time,without notice,to shut off or turn on the wat supply for repairs,construction,and f nonpayment of charges r any her reaso le cause.1 a fh owner,or I am authorized by the owner of this property to perform th w for ich icatio ade, d I omply with the State Contractors Law 18.27 PERMIT# RCW and 296.200 I I /`� U '�rn I O r/Au zed A en gnature ' Date ( ( (Revised 10/`12/2015)