2222 STATE ST 2019-07-09 - Laserfiche WebLink

WATER / SEWER UTILITY APPLICATION s4idCITY 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: 1ZZZ. (Sfi ,fie gr. IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR ATTACHED 0 DULEX 0 MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL 0 INDUSTRIAL CHANGE OF USE? Xl\.1.2 ❑YES, FROM TO UTILITY APPLICATION INFORMATION SEWER(check all that apply) WATER(check all that apply) X1 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 ❑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: SIi'V1J" , 'rOIk) ellTENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET 22 I eji,'e S.* {j�///�� CIN ei STATE VOA • ZIP y�� OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: A-Pr P,viiiiiilem CONTRACTOR ADDRESS: STREET y I hV a, . CITY STATE IA • ZIP *102156 CONTRACTOR PHONE:� � ® O12') CO TRACTOR EMAIL: \141 bl 1 *1 06144014 IOWA tt// CONTRACTOR LIC #(REQUIRED) Jlie I NQ CITY OF EVERETT BUSINr LIC.#(REQUIRED) PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR ❑OTHER(Please Specify) CONTACT NAME: . CONTACT PHONE: DVA-'4%.,,,,)6' 22-96121 Ner16 o11 ( CONTACT,EMAIL: I / 1 WIv1.l1 i ( LL✓ `(5 e AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal lode Title City of Ever t Official Use Only 14 Water and Sewer or such other rules and regulations now existing or which maybe established from time to FEE CO time. The applicant further agrees, - a coni"'n precedent to receiving service that the utilities division shall have . -� /t the right at any " e,w" • t notic ,to shut off o turn on the water supply for repairs,construction,and /J1/`/1 • nonpayment• ch ar.-s or or an other reasona,le cause.I am the owner,or!am authorized by the owner of this property top-- or he wohich applicatlo is made,and I comply with the State Contractors Law 18.27 PERMIT# RCW and 29;200, WA=� ' t 4O5— O 3 Owner/Authoriz-.`,,gent Sigeature Date (Revised 10/12/2015) 'J