2016 78TH PL SE 2020-01-14 - Laserfiche WebLink

WR / SEWER UTILITY PLICATION I�►' a y- 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 PROJECT SITE INFORMATION PROJECT ADDRESS: ZA,9(6, 75 j ase E i je vct f C IF APPLICABLE: ❑OUTSIDE CITY LIMITS 0 BUILDING AREA a i�r� E) SF 0 LOT# M13 le BUILDING TYPE: 0 SFR 0 MULTI-FAMILY 0 COMMERCIAL . ❑ INDUSTRIAL - CHANGE OF USE? "ANO 0 YES, FROM TO UTILITY APPLICATION INFORMATION SEWER(check all that apply) WATER(check all that apply) ❑SIDE SEWER REPAIREW WATER SERVICE INSTALLATION ❑SIDE SEWER ALTERATION 0 COMPLETE SERVICE (METER ONLY lisiNIEW SIDE SEWER INSTALLATION SERVICE/METER USE: ❑INSTALL BACKWATER VALVE(outside the building) '.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: ❑1 AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER 0 FIRE: 1", 2", 4", 6", 8", OTHER: SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER 14 DOMESTIC/FIRE COMBO: 0 2", OTHER: SINGLE OWNERSHIP.RILL OUT REVERSE SIDE OF THIS FORM. CONTACT INFORMATION OWNER NAME:pi/pine_ i9 / 7'$ &LC- TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET / -O 5Ca .:-G/e.rcf Ma f( ti.„) Y Su E k /DA - }} crry �'CJe.''c.7 f-' STATE Lar:A, ZIP ?� / OWNER PHONE: aS " <3 3 - v"2 V)A OWNER EMAIL: 1,414l✓i..4 j�cjD �l'10!�e S , Ga ► CONTRACTOR NAME: 5 iG H vst e 5 L CONTRACTOR ADDRESS: STREET E�O 5 i.ts (J C 71 Mc;/I t.�� p `5 4c� F- .- IC C) crry V e(O STATE (4 1 ZIP 9 D--b1 CONTRACTOR PHONE i)5- T5 3- .P S Cd CONTRACTOR EMAIL: I&}iA}Ldt j Q ct c,z,L t.,ym e S 4 Go Pr) c3 CONTRACTOR LICENSE#(REQUIRED):5 .0:4/7//15.5i C -7 CITY OF EVERETT BUSINESS LICENSE#(REQUIRED):05a33 f PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR gOTHER(Please Specify) CONTACT NAME: CONTACT PHONE: 11 a5 -- 3 is ,„)y3 0 05-e Y L.--- CONTACT EMAIL: a- , T @ 5ec pczG b 001 es, f✓o141 AGREEMENT:The undersigned applicant 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 FEE time.The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have In /� the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and V �,0" ' nonpayment of charges or for any other reasonable cause.lam the owner,or!am authorized by the owner of this property to perform the work for which application is made,and I comply with the State Contractors Law 18.27 PERMIT# ROW and 296.200A WAC. .1/11677— /6' U HP02'118 Owner/Authorized Agent Signature Date (Revised 09125/2015)