3422 HOYT AVE 2019-01-28 - Laserfiche WebLink

T / SEWER UTILITY APPLICATION '411CITY 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,INFORMATIORI PROJECT ADDRESS: 22L1');), r IF APPLICABLE: 0 OUTSIDE CITY LIMITS ❑ BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? 4tiKNO ❑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: lit 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: VANYAA jV (it/ TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: At Qimiimilie� 4 CONTRACTOR ADDRESS: STREET l Yfil • CITY STATE WA, • /ZZIIP �, CONTRACTOR PHONE:(i 0123 CO TRACTOR EMAIL: 1 bf 1 1 VG� I:COM CONTRACTOR LIC.#(REQUIRED): LA liliirT' �NQ CITY OF EVERETT BUSINµV LIC.#(REQUIRED) ® � � .. PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: • CONTACT PHONE: L� � 1 2,'16121 2,' /1(VIM �e Y � t� t V CONTACT EMAIL: A I �V1.IOI 6 C '� `1�✓�1�IWII •`-G" ` AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal ode Title City of Everitt Official Use Only A 9 PP 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 cons"'n precedent to receiving service that the utilities division shall have �fC the right at any ' e,w" t notice, to shut off o turn on the water supply for repairs,construction,and J nonpayment 0{f ch r•-s or or an. other reasona'le cause.l am the owner,or l am authorized by the owner of this iii property to peI'for he wo hich applicatio is made,and 1 comply with the State Contractors Law 18.27 PERMI ` RCW and 29:200• WAC . / U y it,® 1(6 ,_ , o Owner/Authoriz••- •gent Sig lature Date (Revised 10/12/2015)