3925 SMITH AVE 2022-05-16 - Laserfiche WebLink

ATE I SEWER UTILITY( APPLICATION '411CITY 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: /2162,5 }i 141 IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL 0 INDUSTRIAL CHANGE OF USE? IXNO 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: 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. CONTACTQINFORMATION ' OWNER NAME: 0411' 4+ Q�/ I eY / TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: 4 1t + C 4 CONTRACTOR ADDRESS: STREETeAtotA 1 V IbtitICA CITY 77Y// `ill STATE WA, • ZIP at 02/16 9 `fmOLA CONTRACTOR PHONE: ` , i ♦ CO TRACTOR EMAIL: I 1 I 1_fl L I. 1 v &r a _44 1 A 1 1 �, i CITY OF EVERETT BUSIN LIC #(REQUIRED) ° j,_ CONTRACTOR LIC #(REQUIRED) Y� �' ��,.., � .,, .... ._.,�. , „�, ........ � �,�a/."�°_,,_, PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: Lill/S-4')61 2 2 —99�1�°q e OA/Y-116 �I\ 1 CONTACT EMAIL: /� /� 1 VVi�Vd i Iles Rio I t AGREEMENT..The undersigned applicant agrees to comply with all provisions of the Everett Municipalt � dode Title \+ City of Evert Official Use Only g Ap 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to time.The applicant further agrees, a coni FEE precedent to receiving service that the utilities division shall have .,c the right at any ' e,w' . t notice to shut off o turn on the water supply for repairs,construction,and nonpayment if ch"r.-s or or an:otherreasons+le cause.I am the owner,or I am authorized by the owner of this property top- or he wo'k . . hich applicatio is made,and I comply with the State Contractors Law 18.27 PER # RCW and 29:200 WAC . ` , 1 I u 00 DO/ )('' ,_ I �-Il llllllW� wner/Authoriz-• ,gent Sig,ature Date (Revised 10/12/2015)