3212 RUCKER AVE 2018-07-19 - Laserfiche WebLink

�_ WATER / SEWER UTILITY APPLICATION CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P)425-257-8810 I FAX 425-257-8857 1 (E) everetteps@everettwa.gov www.everettwa.gov/permits PROJECT SITE,INFORMATION PROJECT ADDRESS: 2,/\?_..., e 1/1,04-642-- IF /I,( ej2--IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL • CHANGE OF USE? YLIO ❑YES,_ FROM TO , UTILITY APPLICATION INFORMATION SEWER(check all that apply) WATER(check all that apply) .SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION ❑SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: O INSTALL BACKWATER VALVE(outside the building) 0 SFR ❑SIDE SEWER CAP-OFF 0 MULTI-FAMILY-#OF UNITS: ❑SIDE SEWER RECONNECTION . 0 COMMERCIAL MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE: (circle desired size) O I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR \0 DOMESTIC: 3/4", 1", 2", OTHER: MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. v❑ IRRIGATION: 3/4", 1", 2", OTHER: ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER 0 FIRE: 1", 2", 4", 6", 8", OTHER: SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER' 0 DOMESTIC/FIRE COMBO: 1", 2", OTHER: SINGLE OWNERSHIP. FILL QUT REVERSE SIDE OF THIS FORM. CONTACT INFORMATION OWNER NAME: TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET CITY STATE ZIP OWNER PHONE: . OWNER EMAIL: CONTRACTOR NAME: P> CONTRACTOR ADDRESS: STREETvad I V flAY44141C00 . CITY _ STATE WA,, • ZIP at 022:46 01 a� limbi 1 le, CONTRACTOR PHONE: CO TRACTOR EMAIL: � 9 *WI J n CONTRACTOR LIC.#(REQUIRED): t CITY OF EVERETT BUSIN LIC #(REQUIRED)• G S ...-.,�., ...v._w....MN.�.,...-,M �. .,....., .,�.,.>Aft w..,�� ,,..� �.... m�.l..�� PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: • CONTACT PHONE: .L�2S Lb i C,2: a r 6 I� vV41 yit41CONTACT EMAIL: /� / II I VI/b�.Lr1I 1 I�i l® btt tviAI o£, AGREEMENT The undersigned applicant agrees to comply with all provisions of the Everett Municipal I•de Title City of Ever Official Use Only 14 Water and Sewer or such other rules and regulations now existing or which maybe established from time to FEE time.The applicant further agrees, a con rti= precedent to receiving service that the utilities division shall have cP the right at any ' e,wpm t noticoto shut off ok turn on the water supply for repairs,construction,and * *® "� nonpayment of char bs or. or an 1 other reasona le cause.I am the owner,or!am authorized by the owner of this "'ttt property to pel orn)the wo •r hick applicatio is made,and I comply with the State Contractors Law 18.27 PERMIT# RCW and 29 200 WAC W„ . 0 21) �\c� U 1'6 02- 02,Ca CSwner/Authoriz- gent Sig ature Date (Revised 10/12/2015)