3708 ROCKEFELLER AVE 2022-05-12 - Laserfiche WebLink

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 I www.everettwa.gov/permits ',f PROJECT SITE.INFORMATION PROJECT ADDRESS: [?0$ �codi "{o I Lev- ` IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX DMULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? X.N.12 0 YES, FROM TO UTILITY APPLICATION INFORMATION, SEWER(check all that apply) WATER(checkall that apply) ❑SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION ❑SIDE SEWER ALTERATION ❑ COMPLETE SERVICE 0 METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: tkINSTALL 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 ,�f 1 OWNER NAME: e M ' JOfrt1/1,cavk.„. TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: A' s (p CONTRACTOR ADDRESS: STREETeAtatta ' y b Arti• CIN STATE WA . ZIP a,tate n 4� %%�� s CONTRACTOR PHONE: !p,. ®' CO TRACTOR EMAIL: \ bl 1 'ts' 'l V 1. CONTRACTOR LIC.#(REQUIRED): IAA 0t CITY OF EVERETT BUSIN LIC #(REQUIRED) ® 1 ap_.. PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 0 OTHER(Please Specify) r��,,, (� CONTACT NAME: , CONTACT PHONE: L gin �q _ 21 t PA\ k CONTACT EMAIL: A / 'II (VVivL1rJirk, l lc pP 2410'4 I seeWi AGREEMENT..The undersigned applicant agrees to comply with all provisions of the Everett Municipal ILde Title \... City of Everitt Official Use Only 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to FEE CO time. The applicant further agrees, ,. a con r' n precedent to receiving service that the utilities division shall have ��` the right at any ' e,w' . t notice,to shut off o turn on the water supply for repairs,construction,and ,.,/ nonpayment df ch r.-s or or an:other reasons le cause.l am the owner,or I am authorized by the owner of this property to pe for he wo ` hich applicatio is made,and I comply with the State Contractors Law 18.27 PERMIT# RCWand 29:200 +� ' / irt6� 1)(\wner/Authoriz- 4'gent Sig1ature Date (Revised 10/12/2015)