4511 RIVERFRONT BLVD 2018-12-26 - Laserfiche WebLink

#1111P00./44".:'=" WA ER / SEWER UTILITY AOPLICATION - 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 'zsztaitiostea \\, % ✓ I i$ p • iS \\\ra\ 'pep PROJECT ADDRESS: 4511 Riverfront Blvd. IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ODULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? 0 NO 0 YES, FROM TO aArT,. _.. .... ,2 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: 0 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. IRRIGATION: 3/4", 1", ®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. CcN I ACT iNF©R ,. OWNER NAME: Polygon WLH, LLC TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET 11624 SE 5th St, Suite 100 CITY Bellevue STATE WA ZIP 98005 OWNER PHONE: 425.586.7700 OWNER EMAIL: doug.ross@polygonhomes.com CONTRACTOR NAME: Polygon WLH, LLC CONTRACTOR ADDRESS: STREET 11624 SE 5th St. Suite 100 CITY 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: 0 OWNER 4CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: 425.765.2889 Doug Ross CONTACT EMAIL: doug.ross@polygonhomes.com AGREEMENT:The undersigned applicant agrees to comply with all 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 maybe established from time to FEE /y /� D time. The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have 11I1V'/'/11� 4 the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and --^ nonpayment of charges or for any other reasonable cause.I am the owner,or I am authorized by the owner of this property to perform the work for which application is made,and I comply with the State Contractors Law 18.27 PERMIT# RCW and 296.20 WAC . ani 09/07/2017 ii Ob Owner/Authorized Agent Signature Date (Revised 10/12/2015)