2010 ROCKEFELLER AVE 2022-05-11 - Laserfiche WebLink

WATER / SERVER UTILITY APPLICATION 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: 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: *NSTALL 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: TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: KA t� CONTRACTOR ADDRESS: STREET V Alto CITY STATE WA s ZIP CONTRACTOR PHONE: CO TRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): Pt CITY OF EVERETT BI SIN LIC.#(REQUIRED)1 D PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: m� L1 Ilb 5—d IZ CONTACT EMAIL: U e' AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Ida 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 i' precedent to receiving service that the utilities division shall have (1 n.p C7 the right at any e,w' t notic , tout off o turn on the water supply for repairs,construction, and IIID! IVI nonpayment ch r s or or another reasona /e cause.l am the owner,or l am authorized by the owner of this property top or he wohich applicatio is made,and I comply with the State Contractors Law 18.27 PERMIT# RCW and 29 200 WAC caner/Authoriz gent Sig atum Date (Revised 10/12/2015) 1