3405 BELL AVE 2019-09-04 - Laserfiche WebLink

a ,xy W.r a a ER I SEWER UTILITY -PLC*T • OREMSERVICES -rI • 3200 CEDARCITYF EVESTREETTT,PEREVEREITTT, WA 98201 (P)425-257-8810 I FAX 425-257-8857 I (E) everetteps@everettwa.gov I www.everettwa.gov/permits l PROJECT SITE INFORMATION PROJECT ADDRESS: if OS c3ef/ Ave- CV"efoi �Ilq E5';c) t IF APPLICABLE: ❑OUTSIDE CITY LIMITS ❑ BUILDING AREA SF 0 LOT# BUILDING TYPE: iXFR-DETACHED EISFR-ATTACHED ❑DULEX DMULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? ❑NO 0 YES, FROM TO UTILITY APPLICATION INFORMATION SEWER(check all that apply) WATER(check all that apply) SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION D SIDE SEWER ALTERATION 0 COMPLETE SERVICE ❑ METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: O 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 ❑ DOMESTIC/FIRE COMBO: 1", 2", OTHER: SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. CONTACT INFORMATION OWNER NAME: )p plass" / `yIQ! TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET j C bfx�7 AlA/ Lg1 S?L �,cAr C�G� CITY 14-k. STATE ✓✓" ZIP [ C/U? OWNER PHONE:' 7fl lj. — '� OWNER EMAIL:, Gtille_s- 02aV`lia--& i�� ( ". .. CONTRACTOR NAME: Al U ( '-3f CG664i(• ocJ CONTRACTOR ADDRESS: STREET (7// ,Y _557(4 Ave 5 21 cm, C /17- STATE �" ZIP • 3 CONTRACTOR PHONE: a.ao- 7 -- ge6,5 CONTRACTOR EMAIL: ,r� CONTRACTOR LIC.#(REQUIRED) AIS -U rCr OLP-162- CITY OF EVERETT BUSINESS LIC.#(REQUI D): tf?00(e)1 PRIMARY CONTACT: , I% OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: CONTACT PHONE:w} .Dtio ' 3g -7/s� � c /- CONTACT EMAIL: AGREEMENT:The undersigned applici7t agrees to comply with all provisions of the Everett Municipal Code Title City of Everett Official Use Only 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, as a condition precedent to receiving service that the utilities division shall have the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and 30 ...-- - nonpayment of charges or for any other reasonable cause.I am the owner,or I am authorized by the owner of this - property to perform the work for which application is made snd I comply with the State Contractors Law 18.27 PERMIT# RCW and 296.2001 AC. 2- 5 . '(� ` 2- c -/ -r/% U xv er/Authorized Agen Signal •- Date (Revised 10/1212015)