4012 RUCKER AVE 2022-05-12 - Laserfiche WebLink

/ .WAT_ WA , SEWERUTILITY APPLICATION 441WCITY 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 ' �� PROJECT SITE INFORMATION° PROJECT ADDRESS: I ' •" •tlikaW IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: DCOMMERCIAL ❑INDUSTRIAL CHANGE OF USE? LNO 0 YES, FROM TO UTILITY APPLICATION INFORMATION, SEWER(check all that apply) WATER(check all that apply) ❑SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION ❑ SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: g 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 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: ifil ` e` Da,V`,�7 TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: lifv 1 - f,MIA f r A CONTRACTOR ADDRESS: STREET- - 1 biro. CITY „ ,,e4' STATE WA, • ZIP a ( ��ry� /� CONTRACTOR PHONE:l Y1/J'J Wyk0124 CONTRACTOR EMAIL: pt 1 tt� I �, V-ti(�1I• CONTRACTOR LIC #(REQUIRED) �' , t P CITY OF EVERETT BUSINI�LIC #(REQUIRED) PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: • CONTACT PHONE: L142013.4)'I 2S-96121 1 ✓ 1` `,/t 1 vocilet..---- CONTACT EMAIL:A m I1,14146i-1,17 j4 6 I 6 ILS 2410 lim�!/41 .AGREEMENT.The undersigned applicant agrees to comply with all provisions of the Everett Muniicipal node Title City of EveOfficial Use Only 14 Water and Sewer or such other rules and regulations now existing or which maybe established from time to FEE time.The applicant further agrees, a cone'• precedent to receiving service that the utilities division shall have y1r) the right at any ' e,w” • t notice,to shut off o turn on the water supply for repairs,construction,and 417 o nonpayment• ch'r•-s or or an otherreasona4le cause.I am the owner,or am authorized by the owner of this property top- or he wo . hich applicatio is made,and I comply with the State Contractors Law 18.27 MIT / ` RCW and 29;200 WAC u c J\1(, o2,vjl Owner/Authoriz-i'gent Sig/ature Date (Revised 110//9112/2`015) G