6221 CADY RD 2019-05-29 - Laserfiche WebLink

WATER I SEWER UTILITY APPLICATION 4 yr 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 4 PROJECT SITE INFORMATION PROJECT ADDRESS: 1#22 p_44. IF APPLICABLE: 0 OUTSIDE CITY LI TS ❑ BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? lt2itC2 0 YES, FROM TO __ .. UTILITY'APPLICATION INFORMATION SEWER(check all that apply) WATER(check all that apply) li SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION ❑SIDE SEWER ALTERATION ❑COMPLETE SERVICE 0 METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: El INSTALL BACKWATER VALVE(outside the building) 0 SFR ❑SIDE SEWER CAP-OFF ❑ 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: TENANT NAME((If Commercial): ��C.`G. �,<11�,R�t OV DO �Y't� � � OWNER MAILING ADDRESS: STREET CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: A e s P,0414 • CONTRACTOR ADDRESS: STREETegtra ' Y fiAit, terrei. CITY STATE Wet,/� • ZIP 'e,o CONTRACTOR PHONE:U'[ At 0124 CO TRACTOR EMAIL:A.� `I t GA Ilii-' I l _ , iI®lm .C, CONTRACTOR LIC.#(REQUIRED): IA14 0 I La CITY OF EVERETT BUSIN LIC.#(REQUIRED): O PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: • /j CONTACT PHONE: L� � 1 2.,b-9-I 21 NY 6 c4\ VA, CONTACT EMAIL: / iI 11A41I,t j 6 .lam 1O4ft\61/ll ,e6,1,0 AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett MunicipallI*de Title City of Evert Official Use Only 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to FEEp® time. The applicant further agrees, a con iti.n precedent to receiving service that the utilities division shall have the right at any rpe, s" •ut notic ,to shut off o\turn on the water supply for repairs,construction,and � nonpayment /f char es or or anyother reasona�le cause.l am the owner,or I am authorized bythe owner of this q • property top orrr he wo r, hick applicatio is made,and I comply with the State Contractors Law 18.27 PERMIT# RCW and 29:`2001 P.- ou\q C n OwnerlAuthoriz gent Sig ature Date (Revised 10/12/2015)