1618 BAKER AVE 2018-06-16 - Laserfiche WebLink

VA -ER / SEWED UTILITY JWPLICATION 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 _IP SIDE SEWER REPAIR ❑ SIDE SEWER ALTERATION ❑ NEW SIDE SEWER INSTALLATION ❑ INSTALL BACKWATER VALVE (outside the building) ❑ SIDE SEWER CAP -OFF ❑ SIDE SEWER RECONNECTION MULTIPLE DOMESTIC WATER SERVICES REQUEST ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR MY MULTI -FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ l AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER SERVICES FOR MY MULTI -FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. CONTACT INFORMATION ❑ NEW WATER SERVICE INSTALLATION ❑ COMPLETE SERVICE ❑ METER ONLY SERVICE / METER USE: ❑ SFR ❑ MULTI -FAMILY -# OF UNITS: ❑ COMMERCIAL WATER SERVICE TYPE / SIZE: (circle desired size) ❑ DOMESTIC: 3/4", 1", 2", OTHER: ❑ IRRIGATION: 3/4", 1", 2", OTHER: ❑ FIRE: 1", 2", 4", 6", 8", OTHER: ❑ DOMESTIC/FIRE COMBO: 1", 2", OTHER: OWNER NAME: S r t% TENANT NAME (If Commercial): -_ OWNER MAILING ADDRESS: STREET CITY / ,t STATE __- --- _ OWNER PHONE 1 % /S%`t' (OWNER EMAIL CONTRACTOR NAME pis p/ T d.L2_ _ CONTRACTOR ADDRESS: sTREETJZ�� l,S.4-_/� -= STATE ZIP 6 (�! (Y - _ ,-cirY _Sc��4�_. - -_ CONTRACTOR PHONE:C-2-SA-S-27 0 !CONTRACTOR EMAIL: CONTRACTOR LIC. #(REQ_ UIRED): A/t-K-. (CITY OF EVERETT BUSINESS LIC #(REQUIRED):_0 S 3 24 / PRIMARY CONTACT: ❑ OWNER-toONTRACTOR ❑ OTHER (Please Specify) _ CONTACT NAME: I CONTACT PHONE: Z S _ S 6 _ p 4 D CONTACT EMAIL: n N-�jv AGREEMENT. The undersigned applicant _— — g PP 9 ' precedent to existing service that the utilities division shall have FEE tY Use Only ant a Tees to comply with all provisions of the Everett Municipal Code Title C� of Everett official U 14 Water and Sewer or such other rules and regulations now existing or which maybe established from time to -- '" time. The applicant further agrees, as a condition pre g the right at any time, without notice, to shut off or tum on the water supply forrepairs, construction, and nonpayment of charges or for any other reasonable cause. 1 am the owner, or 1 am authorized by the owner of this -_ -� �,• - _ property to erform the work f r hich application is made, and I comply with the State Contractors Law 18.27 M - �J u p y p pp � PERMIT # RCW and 29 00A WAC. U a 07 10 Owner/Authorized Agent Signature Date (Revised 10/12/2015)