4012 HIGH ST 2018-12-26 - Laserfiche WebLink

WATER / SEWER UTILITY APPLICATION ,NtirCITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P)425-257-8810 I FAX 425-257-8857 I (E) everetteps@everettwa.gov www.everettwa.govlpermits • ;, PROJECT SITE`INFORMATION PROJECT ADDRESS: ii0 2 ` ✓J 1 h Ve/J- IF APPLICABLE: 0 OUTSIDE CITY LI1ITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? NO 0 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: 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) ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR 0 DOMESTIC: 3/4", 1", 2", OTHER: MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. 0 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 OUT REVERSE SIDE OF THIS FORM, CONTACT INFORMATION OWNER NAME J)kk * ft 4(& DVI rtY. TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET CITY STATE ZIP OWNER PHONE: OWNER EMAIL: n.N CONTRACTOR NAME: A-Pr P 40)iti CONTRACTOR ADDRESS: STREET I 1,/VW14 ittitti. CITYeetnytt STATE EA A� • ZIP et 0 CONTRACTOR PHONE:!Y[ At®123 CONTRACTOR EMAIL: \ ,I; , /I h�III��o 1 le, 1®I •I'NW CONTRACTOR LIC.#REQUIRED: b CITY OF EVERETT BUSIN LIC.#(REQUIRED): 0 51 5540 PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: • �/� tg /� CONTACT PHONE: L/HIS 122 —i 12I1 r 6 10 ` \, 1 1(4 CONTACT EMAIL: 4 / iI I 1A414144,147 VIR.IO I ( (C. 2,4119/w4441 o AGREEMENT.'The undersigned applicant agrees to comply with all provisions of the Everett Municipal d ode Title City of EveOfficial 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.] precedent to receiving service that the utilities division shall have �` ��` the right at any " e,w" • t noticoff to shut o turn on the water supply for repairs,construction,and _qI ib ./ nonpayment• ch,-r.-s or or an other reasona,le cause.I am the owner,or I am authorized by the owner of this property top- or he wo hich applicatio is made,and I comply with the State Contractors Law 18.27 PERMI # RCW and 29;200, WAC wner/Authoriz-1,•gent Sig lature Date (Revised 10/12/2015)