2809 23RD ST 2017-10-20 - Laserfiche WebLink

WATER 1 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: u I IZF$ 0-- 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? I�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: ►1 1 TENANT NAME(If Commercial): OWNER MAILING AD &ESS: STREET CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: CONTRACTOR ADDRESS: STREET CITY STATE • ZIP CONTRACTOR PHONE: CO TRACTOR EMAIL: JIM1 CONTRACTOR LIC.#(REQUIRED)_.WM IZ4 0 11 Fb CITY OF EVERETT BUSIN LIC.#(REQUIRED): D PRIMARY CONTACT: ❑OWNER ❑ CONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: 1 CONTACT PHONE: !/J C5 Z (IAS.Ylj �� l ��"`�/t A' CONTACT EMAIL: ( c ` AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Jode 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 VID the right at any " e,w' t notic , to shut off o turn on the water supply for repairs,construction,and nonpayment f ch r s or or an other reasona le cause.l am the owner,or/am authorized by the owner of this property to p or he wo hich appticatio is made,and I comply with the State Contractors Law 18.27 PERMIT# RCW and 29 200 WAC U caner/Authoriz gent Sig afore Date (Revised_10/1212015)