3425 RUCKER AVE 2018-12-26 - Laserfiche WebLink

0001111P, , WATER / SEWER UTILITY APPLICATION 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 r PROJECT SITE INFORMATION, PROJECT ADDRESS: Vt./0,67 .vaiHipe). 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? 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: otnri s 411:14114., nAt.V Ite4AME(If Commercial): `/Y .+1�� OWNER MAILING ADDRESS: STREET tool JL J}�� J/��` � '��` CITY Vv& `�'JI.a {/I' {�7 STATE WA ZIPotc2. OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: Alko'ler p r CONTRACTOR ADDRESS: STREETegtvsa 1 V'WL± a, CITY STATE WA, • ZIP 010206 CONTRACTOR PHONE:Uot n OV _CO TRACTOR EMAIL:a jek./plIANV tl AL1 O •1 ICsaVIACONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSILIC.#(REQUIRED): 0 PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT^NAME: CONTACT PHONE: LLt1) 2�y i 6121 /IAS„Y 6 P`\ V,, CONTACT EMAIL: / / �I I[MX 144(11. [ [c, 214-70 lm m, .Cam AGREEMENT.. The undersigned applicant agrees to comply with all provisions of the Everett Municipal I.de Title City of Everitt 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 con i' precedent to receiving service that the utilities division shall have the right at any ' e,w" • t notice,to shut off o turn on the water supply for repairs,construction,and 4430 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 wohich applicatio is made,and I comply with the State Contractors Law 18.27 PERMIT# RCW and 29:200' W C '� 1,,...� b.- u ir D 15 0)(4caner/Authoriz•4.gent Sig,ature Date (Revised 10/12/2015)