2209 HOYT AVE 2017-10-20 - Laserfiche WebLink

WATER / SEWER 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: !iZ(�" I IF APPLICABLE: ❑OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? YNO ❑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: )I 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) ❑ 1 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: 111 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: U TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET IA A-2 CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: ar '^ CONTRACTOR ADDRESS: STREET V CITY STATE A • ZIP s CONTRACTOR PHONE: LL4, W. CO TRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSIN LIC.#(REQUIRED): O PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR ❑ OTHER(Please Specify) CONTACT ^NAME: • CONTACT PHONE: !/J C.t 5�t7 Z CONTACT EMAIL: AGREEMENT::The undersigned applicant agrees to comply with all provisions of the Everett Municipal Jode Title City of Ever&lt 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 i. n precedent to receiving service that the utilities division shall have the right at any ' e,w' t not CC ,to shut off o turn on the water supply for repairs,construction, and nonpayment ch r s or or an other reasona le cause.l am the owner,or 1 am authorized by the owner of this property to p or he wo hich applicatio is made,and I comply with the State Contractors Law 18.27 PERMIT# RCW and 29 200 WAC V caner/Authoriz gent Sig ature Date (Revised 10/12/2015) /J