4809 EVERGREEN WAY CLUBHOUSE GRILL 2022-04-14

WA�'ER / ��1�� `�0�1`�Y ��LIC�`�ION CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P) 425-257-8810 � FAX 425-257-8857 � (E) everetteps@everettwa.gov � www.everettwa.gov/permits PROJECT SITE INFORMI4T10�1 �- PROJECT ADDRESS; � �q _ 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? ❑ NO ❑YES, FROM TO UTILITY APPLICATION INFORMATION SEWER(check all that apply) WATER(check all that apply) �IDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION ❑ SIDE SEWER ALTERATION ❑ COMPLETE SERVICE ❑ METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: ❑ 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: �� G i' � I TENANT NAME(If Commercial): OWNER MAILING ADDRESS: s-rReET CITY STATE Z�P OWNER PHONE: OWNER EMAIL: .. � � :.---. ._. __,... .. ... ....._. _.. . CONTRACTOR NAME: � ` "I�� CONTRACTOR ADDRESS: sTReeT i��C�;ti> � � v� CITY � Cn STATE �'✓ G ZIP ��I . CONTRACTOR PHONE: 'z ""� � �-�Z`7 CONTRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): Q SC I CITY OF EVERETT BUSINESS LIC #(REQUIRED): �7 �`Y ..... _.�.,,.,,_.... ....... . .... ,, .._. .. . . PRIMARY CONTACT: ❑OWNER CONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: LIZ,� -3 � U � K (� 1 � �� // CONTACT EMAIL: AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Evereft Municipal Code Title City of Everett Offcial Use Only 14 Waterand Seweror such other rules and regulations now existing orwhich may be established from time to FEE time. The applicant fu�ther agrees, as a condrtion precedent to receiving seivice that the utilities division shall have the right at any time,without notice,to shut off or turn on the water supply for repairs,construcfion,and nonpayment of charges or for any other reasonable cause.1 am the owner, or I am authorized by fhe owner of this properfy to perform the work for which application is made,and 1 comp/y with ihe State Confractors Law 98.27 PERMIT# RCW and 296200A WAC. � , � , -�-- lC> Zc:� e OwnerlAu ed Agent Signature Date (Revised 10/92/2015)