4205 RIVERFRONT BLVD COE LIFT STATION #42 2018-03-27

W�ER / SEWER UTILITY �PLICATION 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 S1T�'IN��'�►IYtMATIDN ' ,, ,, , � , PROJECT ADDRESS: !��) � , ` �, � � � IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑�NDUSTRIAL CHANGE OF USE? ❑ 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: ❑ 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. 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", n 2", OTHER: SINGLE OWNERSHIP. FILL OUT REVERSE S/DE OF TH/S FORM. CON CT INFORMATION OWNER N �ME: POIy 'rl��W�H, LLC �'� � +-_�� ; �TENANT NAME(If Commercial): OWNER MAILIN(3�QDDR SS: sr�eeT 11 4 S ' $ Suite 100 `-.. cirv �`� 211evU2 � srAre WA ziP 98005 OWNER PHONE: 425.586.7700 NER EMAIL: 818n. 8111 OI onhomes.com CONTRACTOR NAME: POlyg011 WLH, LLC CONTRACTOR ADDRESS: srReET 11624 SE 5th St, Suite 100 cirv Bellevue STATE WA ziP 98005 CONTRACTOR PHONE: 425.586.7700 CONTRACTOR EMAIL: ron.bowen@polygonhomes.com CONTRACTOR LIC.#(REQUIRED): 603422796 CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 053221 PRIMARY CONTACT: ❑ OWNER CONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: 425.765.2889 Doug Ross CONTACT EMAIL: doug.ross@polygonhomes.com AGREEMENT: The undersigned applicant ag�ees to comply with al/provisions of the Everett Municipal Code Title City of Everett 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,as a condition precedent to receiving service that the utilities division shall have y � _ _�,-, / the right at any time, without notice,to shut off o�turn on the water supply for repairs,construction, and �.� t ��_�I ; � nonpayment of charges or for any other�easonable cause. 1 am the owner,or 1 am authorized by the owner of this � �" property to perform the work for which app/ication is made,and I comp/y with the State Contractors Law 18.27 PERMIT# RCW and 296.20 WAC • Q.QA.l1, �_ �q.rU. 09/21/2016 U ; ` �` � +, � ' Owner/Authorized Agent Signature Date (Revised 10/12/2015)