2205 HOYT AVE 2017-10-20 - Laserfiche WebLink

WATER / SEINER UTILITY APPLICATION 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: 'ZZ��j IF APPLICABLE: ❑OUTSIDE CITY LIMITS ❑ BU! REA SF ❑ LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED YDULQ❑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 ❑ NEW WATER SERVICE INSTALLATION ❑ SIDE SEWER ALTERATION ❑ COMPLETE SERVICE ❑ METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: YI 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: -(IV TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET v CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: 46 91V CONTRACTOR ADDRESS: STREET VA Air-19. CITY STATE IVA • ZIP CONTRACTOR PHONE: CO TRACTOR EMAIL: rr CONTRACTOR LIC.#(REQUIRED): Xv AA CITY OF EVERETT BUSIN LIC.#(REQUIRED): Q _. PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR ❑OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: MC)4 15- 04y - Z 0 1�A y�1j MCI CONTACT EMAIL: [ � 1gym 60 AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal dode Title City of Ever t 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, a con 7. n precedent to receiving service that the utilities division shall have the right at any - e,w- t notic , to shut off o turn on the water supply forrepairs,construction, and nonpayment f ch r s or or an other reasona le cause.1 am the owner,or I am authorized by the owner of this property to p or he wo hich applicatio is made,and 1 comply with the State Contractors Law 18.27 PERMIT# RCW and 29 200 WAC U caner/Authoriz gent Sig ature Date (Revised 10/1212015) /✓,