4419 30TH DR SE 2021-12-15 - Laserfiche WebLink

WA-:----R / SEWER UTILITY A_=LICATION (P) 425-257-8810 CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits PROJECT ADDRESS: 4415 30th Dr. SE, Everett, WA IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ElBUILDING AREA -+-6$'4 1� SF ❑LOT # 238 IBUILDING TYPE: ®SFR-DETACHED ❑SFR-ATTACHED ❑DULEX []MULTI -FAMILY# OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? ❑ NO ❑ YES, FROM TO I SEWER (check all that apply) I WATER (check all that apply) ❑ 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. ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER SERVICES FOR MY MULTI -FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. IN NEW WATER SERVICE INSTALLATION ❑ COMPLETE SERVICE ❑ METER ONLY SERVICE / METER USE: ❑ SFR ❑ MULTI -FAMILY - # OF UNITS: ❑ COMMERCIAL WATER SERVICE TYPE / SIZE: (circle desired size) IN DOMESTIC: 3/4" 1", 2", OTHER: _ ❑ IRRIGATION: 3/4", 1", 2", OTHER: ❑ FIRE: 11., 2", 4", 6", 8", OTHER: ❑ DOMESTIC/FIRE COMBO: 1", 2", OTHER: CONTACT INFORMATION OWNER NAME: Polygon WLH, LLC TENANT NAME (If Commercial): OWNER MAILING ADDRESS: STREET 11624 SE 5th Street, Suite 100 Bellevue CITY WA STATE 98005 ZIP OWNER PHONE: 425.586.7700 1OWNER EMAIL: alan.pani@polygonhomes.COm CONTRACTOR NAME: Same as Owner CONTRACTOR ADDRESS: STREET CITY STATE ZIP CONTRACTOR PHONE: 425.586.7700 1CONTRACTOR EMAIL: alan.pani@polygonhomes.com CONTRACTOR LIC. #(REQUIRED): polygWl863pW CITY OF EVERETT BUSINESS LIC. #(REQUIRED): 053222 PRIMARY CONTACT: ® OWNER ❑ CONTRACTOR ❑ OTHER (Please Specify) CONTACT NAME: Alan Pani CONTACT PHONE: 425.586.7700 CONTACT EMAIL: alan.pani@polygonhomeS.com AGREEMENT: The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to time. The applicant further agrees, as a condition precedent to receiving service that the utilities division shall have the right at any time, without notice, to shut off or turn on the water supply for repairs, construction, and nonpayment of charges or for any other reasonable cause. I am the owner, or 1 am authorized by the owner of this property to perform the work for which application is made, and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. Oly-P, �_ PaAi. 02/09/17 Owner/Authorized Agent Signature Date City of Everett Official Use Only F 4 1 PERMIT # u ntl3 Ai (Revised 1011212015)