3406 HOYT AVE 2018-12-26 - Laserfiche WebLink

WATER / SEWER TILITY APPLICTI CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT,WA 98201 (P)425-257-8810 I FAX 425-257-8857 I (E) everetteps@everettwa.gov I www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: :1 t D GQ t �, IF APPLICABLE: 0 OUTSIDE CI IMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ODULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL 0 INDUSTRIAL CHANGE OF USE? YILJO 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: li)CINSTALL 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: L ail ,^ n :,G e 6001 TENANT NAME(If Commercial): OWNER MAILING ADDRESS:� STREET CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: Pr ill' P.,viimiii ii CONTRACTOR ADDRESS: STREETeAtort4 1 e CITY STATE Yv • ZIP attieb CONTRACTOR PHONE:!Y[ 01-A CONTRACTOR EMAIL: p,km ti t KA 1 2✓14fl o,lwai i avi CONTRACTOR LIC #(REQUIRED): A leet t Pt) CITY OF EVERETT BUSIN LIC.#(REQUIRED): 0 51551.e PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: . CONTACT PHONE: [MAN)0[22—I'21 Y ✓ Iv d'\ O Y�l. CONTACT EMAIL:� / �I I VVI l.. tic Rio 'w ii •l,�/4" AGREEMENT..The undersigned applicant agrees to comply with all provisions of the Everett Municipal(.de Title City of Evert 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, a coni"•n precedent to receiving service that the utilities division shall haveCO the right at any ' e,w" t notice,to shut off o turn on the water supply for repairs,construction, and . .. nonpayment.f ch'r.-s or or an other reasona.le cause.I am the owner,or am authorized by the owner of this ssssJJJJ��•//// property top- or he wo hich applicatio is made,and I comply with the State Contractors Law 18.27 PERMIT# RCW and 29;200, WAC C ' ik UW6-0 wner/Authoriz-e•gent Sig,ature Date (Revised 10/12/2015)