4010 FEDERAL AVE 2019-05-29 - Laserfiche WebLink

WATER / SEWER UTILITY APPLICATION AI►' CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P)425-257-8810 l FAX 425-257-8857 I (E)everetteps@everettwa.gov( www.everettwa.gov/permits PROJECT SITE'INFORMATION " �'.. � o».,_ - ..,_ ,. _"_- ,. PROJECT ADDRESS: tiDfO Felera Ave. 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? )21'1'10 0 YES, FROM TO _ _ ,, UTILITYAPPL•ICAT,ION INFORMATION, . SEWER(check all that apply) WATER(check all that apply) gDE 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 ❑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. CON OWNER NAME: TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: A o/0 /Amo/ e CONTRACTOR ADDRESS: STREET (( ( Ss '7vk�..'1a Z4 a /s CITY VI (f/ft/R STATE tVj/V` ZIP Qd�j�`p CONTRACTOR PHONE: Ze,G 3 6s Q Q$'I CONTRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): gerigrit Se /ZZ 8 A CITY OF EVERETT BUSINESS LIC.#(REQUIRED):03 77 2Lf PRIMARY CONTACT: 0 OWNER CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: Vernon glAPh CONTACT PHONE: 30.5' dcQ CONTACT EMAIL: l 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 4 22 m the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and U 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 PERMIT# RCW and 2�96. A W C. 2qt u1 i 1 Owner/Authorized Agent Signature Date (Revised 10/12/2015)