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4205 RIVERFRONT BLVD COE LIFT STATION #42 2018-03-27
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COE LIFT STATION #42
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4205 RIVERFRONT BLVD COE LIFT STATION #42 2018-03-27
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Last modified
3/27/2018 10:59:08 AM
Creation date
3/27/2018 10:56:53 AM
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Address Document
Street Name
RIVERFRONT BLVD
Street Number
4205
Tenant Name
COE LIFT STATION #42
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W�ER / SEWER UTILITY �PLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> (P) 425-257-8810 � FAX 425-257-8857 � (E) everetteps@everettwa.gov � www.everettwa.gov/permits <br /> ' PROJECT S1T�'IN��'�►IYtMATIDN ' <br /> ,, ,, , � , <br /> PROJECT ADDRESS: !��) � , ` �, � � � <br /> IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT# <br /> BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑�NDUSTRIAL <br /> CHANGE OF USE? ❑ NO ❑YES, FROM TO <br /> UTILITY APPLICATION INFORMATION <br /> SEWER (check all that apply) WATER (check all that apply) <br /> ❑SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION <br /> ❑ SIDE SEWER ALTERATION ❑ COMPLETE SERVICE ❑ METER ONLY <br /> ❑ NEW SIDE SEWER INSTALLATION SERVICE!METER USE: <br /> ❑ INSTALL BACKWATER VALVE(outside the building) ❑ SFR <br /> ❑ SIDE SEWER CAP-OFF ❑ MULTI-FAMILY-#OF UNITS: <br /> ❑ SIDE SEWER RECONNECTION ❑ COMMERCIAL <br /> MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE: (circle desired size) <br /> ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR �DOMESTIC: 3/4', 1", 2", OTHER: <br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. 1", 2", OTHER: <br /> ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑ FIRE: 1", 2", 4", 6", 8", OTHER: <br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER ❑ DOMESTIC/FIRE COMBO: 1", n 2", OTHER: <br /> SINGLE OWNERSHIP. FILL OUT REVERSE S/DE OF TH/S FORM. <br /> CON CT INFORMATION <br /> OWNER N �ME: POIy 'rl��W�H, LLC �'� � +-_��� ��; �TENANT NAME(If Commercial): <br /> OWNER MAILIN(3�QDDR SS: sr�eeT 11 4 S ' $ Suite 100 `-.. <br /> cirv �`� 211evU2 � srAre WA ziP 98005 <br /> OWNER PHONE: 425.586.7700 NER EMAIL: 818n. 8111 OI onhomes.com <br /> CONTRACTOR NAME: POlyg011 WLH, LLC <br /> CONTRACTOR ADDRESS: srReET 11624 SE 5th St, Suite 100 <br /> cirv Bellevue STATE WA ziP 98005 <br /> CONTRACTOR PHONE: 425.586.7700 CONTRACTOR EMAIL: ron.bowen@polygonhomes.com <br /> CONTRACTOR LIC.#(REQUIRED): 603422796 CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 053221 <br /> PRIMARY CONTACT: ❑ OWNER CONTRACTOR ❑ OTHER(Please Specify) <br /> CONTACT NAME: CONTACT PHONE: 425.765.2889 <br /> Doug Ross CONTACT EMAIL: doug.ross@polygonhomes.com <br /> AGREEMENT: The undersigned applicant ag�ees to comply with al/provisions of the Everett Municipal Code Title City of Everett Official Use Only <br /> 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to FEE ;,, ) <br /> time. The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have y � _ <br /> _�,-, / <br /> the right at any time, without notice,to shut off o�turn on the water supply for repairs,construction, and �.� t ��_�I ; � <br /> nonpayment of charges or for any other�easonable cause. 1 am the owner,or 1 am authorized by the owner of this � �" <br /> property to perform the work for which app/ication is made,and I comp/y with the State Contractors Law 18.27 PERMIT# <br /> RCW and 296.20 WAC • <br /> Q.QA.l1, �_ �q.rU. 09/21/2016 U ; ` �` � +, � <br /> ' <br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015) <br />
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