5034 CREST LN 2019-06-24 - Laserfiche WebLink

ellIP-� 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 J www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: 03 G/G�S ��/' ��`2. 119 s O� IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: $SFR ❑TOWNHOUSE ❑DUPLEX ❑ADU ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑ACCESSORY. CHANGE OF USE? 0 NO YES, FROM S P Z'[ C- TO 6-449 UTILITY APPLICATION INFORMATION SEWER(check all that apply) WATER(check all th-t apply) ❑SIDE SEWER REPAIR 0 NEW WATE" SERVICE INSTALLAT •N ❑SIDE SEWER ALTERATION 0 COMPLE SERVICE 0 METER ONLY KNEW SIDE SEWER INSTALLATION SERVICE/MET— USE: ❑INSTALL BACKWATER VALVE(outside the building) 0 SFR ❑SIDE SEWER CAP-OFF 0 MULTI-FAMI - ° OF UNITS: ❑SIDE SEWER RECONNECTION ❑COMMERIAL MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SE', ICE TYPE/ ZE:(provide calcs to support size choice) ❑I AM DECLIN - MULTIPLE DOMESTIC WATER SERVICES FOR 0 DO STIC: 0 4" 01" 02" ❑Other: MY MULTI-FAMILY D OPMENT DER SINGLE OWNERSHIP. 0 I"IGATION: 03/4 01" 02" ❑Other: ❑IAM OPTING TO INS MUL -L DOMESTIC WATER r, FIRE: 01" 02" ❑ ' 06" 08" ❑Other: SERVICES FO MULTI-FAMILY D- LOPMENT UNDER 0 DOMESTIC/FIRE COMBO: " 02" ❑Other: SIN •WNERSHIP.FILL OUT REVERSE SIDE OF THIS FORM. 0 BACKFLOW PREVENTION(Outside): ORPBA ❑DCDA ❑DCVA CONTACT INFORMATION OWNER NAME: � /7424l _r('"f TENANT BUSINESS NAME(If Commercial): OWNER MAILING ADDRESS: STREET 5' `--" G 2 $ r J,O CITY � STATE C ZIP Tea, U� OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: X) (t y //s a' .� may jG'� Lr 1/4 CONTRACTOR ADDRESS: STREET 2�t/ ' J/ i j/ CITY E��/«7'14- STATE 4) ZIP 7�c. D CONTRACTOR PHONE: Y2-5":" �r�� CONTRACTOR EMAIL: fir,, t ,V e -t Sf�I G `4�'�v'l�w awe.- CONTRACTOR wrCONTRACTOR LIC.#(' !UIRED): =N 1'G(,SS I 0 CITY OF EVERETT BUSINESS LIC.#(REQUI ): pl.3I�,� PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR 0 OTHER(Please Specify) e CONTACT NAME: CONTACT PHONE: {Z�---- --�f�/ CONTACT EMAIL: AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title 14 Water and Sewer or such other rules and regulations now existing or which maybe established from time to time.The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have the right at any time,without notic- 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 ow - of this property to perform the work for which application is made,and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. City of Everett Official Use Only PERMIT# 3/5/ 9 U l9 C - oo9 Owner/Authorized Agent Signature Date (Revised 10/12/2018)