3431 ROCKEFELLER AVE 2018-12-26 - Laserfiche WebLink

WATER / SEWER UTILITY APPLICATION ' �‘444 CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P)425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa,gov 1 www.everettwa.gov/permits PROJECT SITE INFORIVMATION; PROJECT ADDRESS: 1jVb, Oaf/knelt f • IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF ID LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL DINDUSTRIAL CHANGE OF USE? NO 0 YES, FROM TO UTILITY APPLICATION 1NFORMIATION 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: yit INSTALL BACKWATER VALVE(outside the building) 0 SFR ❑SIDE SEWER CAP-OFF 0 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 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: V 1 \ \ i fai4 W C 'COY 1TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET LID 3 t-t' " r _ f I Wal-, Jrl�y/-,, CITY v STATE i ZIP q pn V 4` �. OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: �°�' 1.„1-,,,,„, ,„,,,,. CONTRACTOR ADDRESS: STREET,,,a I CIN STATE Wit, • /aZIP 4, CONTRACTOR PHONE:l )A. D1� CO TRACTOR EMAIL: pi h! 1 i9� Vfl O //�� 4 I SCOW CONTRACTOR LIC #(REQUIRED) t CITY OF EVERETT BUSIN LIC #(REQUIRED) CJ PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: . CONTACT PHONE: LV 112'b-61921 Qv ✓ WW1 \ CONTACT EMAIL: AUV°11 VVYy.Id iyvI IC ` lO4 AGREEMENT..The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title City of Everrtt 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 have it j1 30 .°° the right at any ' e,w' . t notice,to shut off o turn on the water supply for repairs,construction,and nonpayment• ch.r.-s or or an other reasona le cause.I am the owner,or l am authorized by the owner of this iiproperty top-, or he wo i hich epplicatio is made,and I comply with the State Contractors Law 18.27 PERMIT# )C1 RCW and 29:200 WAC ' 9)062-- D n caner/Authoriz-elk.gent Sly ature Date (Revised 10/12/2015)