4225 RIVERFRONT BLVD 2019-03-14 - Laserfiche WebLink

WATER / SEWER UTILITY AF LIGATION i1pr,�_ CITY OF EVERETT PERMIT SERVICES �� 3200 CEDAR STREET, EVERETT, WA 98201 (P)425-257-8810 I FAX 425-257-8857 1 (E)everetteps@everettwa.gov f www.everettwa.gov/permits 412.7.$ IttYV.Frts-At' 01%4 PROJECT-SITE INFORMATION PROJECT ADDRESS: , Everett, WA IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA 1,684 SF 0 LOT# 152 BUILDING TYPE: ®SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? 0 NO 0 YES, FROM TO UTILITY APPLICATION INFORMATION.; SEWER(check all that apply) WATER(check all that apply) ❑SIDE SEWER REPAIR l NEW WATER SERVICE INSTALLATION ❑SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY RI 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 I9 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: Polygon WLH, LLC TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET 11624 SE 5th Street, Suite 100 Bellevue CITY WA STATE 98005 ZIP OWNER PHONE: 425.586.7700 OWNER EMAIL: alan.pani@polygonhomeS.COm CONTRACTOR NAME: Same as Owner CONTRACTOR ADDRESS: STREET CITY STATE ZIP CONTRACTOR PHONE: 425.586.7700 CONTRACTOR EMAIL: alan.pani@polygonhomes.com CONTRACTOR LIC.#(REQUIRED): polygwl863pw CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 053222 PRIMARY CONTACT: ®OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: 425.586.7700 Alan Pani CONTACT EMAIL: alan.pani@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 may be established from time to FEE time. The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have 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 PC I RCW and 296.200A WAC. �T,# 01/05/18 U rt Owner/Authorized Agent Signature Date (Revised 10/12/2015) 3�6/1q