6502 EVERGREEN WAY 2018-05-15 - Laserfiche WebLink

VV� ER / SEVVER lJT'ILITI� i PLICi4TION 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 INFORMATION PROJECT ADDRESS: � '-ii�� 'jf,' ', ��/�� -1-' ' R J � � �, IF APPLICABLE: ❑ OUTSIDE CITY LIMITS . ❑ BUILDING A EA 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) ❑ SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION ❑ SIDE SEWER ALTERATION ❑ COMPLETE SERVICE ❑ METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: ❑ INSTALL BACKVVATER VALVE(outside the building) ❑ SFR I�LSIDE 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: TENANT NAME(If Commercial): OWNER MAILING ADDRESS: srREET CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: � '�� Y ' ' � LQ/�� I_ �� • CONTRACTOR ADDRESS: TREET C�Ty STATE ZIP CONTRACTOR PHONE: CONTRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): U� �� v CITY OF EVERETT BUSINESS LIC.#(REQUIRED): � �j��` PRIMARY CONTACT: ❑OWNER ❑ CONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: CONTACT EMAIL: AGREEMENT:The undersigned applicant agrees to comply with all provisions of fhe Everett Munrcipal Code Title City of Everett Official Use Only 14 Water and Sewer or such other rules and regulations now existing or which may be esta6lished from time to time. The applicant further agrees, as a condition precedent to receiving service thaf the utilities division shall have FEE +1 a ��, XL �� the right at any time, without notice,to shut off or tum on the water supply for repairs,construction,and �� nonpayment of charges or for any other reaso e cause.1 am the owner,or I am authorized by the owner of this " property orm the work for which ap�icafion i�J made,and I comply with the State Cont�actors Law 18.27 PERM IT# . I iC an 296. 00 WAQ�� ' / �-} \ i' � � 1{ � l �� � � � �, ��'�� I�i� I �' � wn uthorized Agent Signature Date (Revised 10/12/2015)