3401 SHORE AVE 2020-01-22 - Laserfiche WebLink

WATER / SEWER UTILITY APPLICATION 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: 34(r) I cS kre CSD e_ IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED ,ZSFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? O 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. CONTACT INFORMATION OWNER NAME: C--1 ►N1 (,a r t/f TENANT NAME(If Commercial): OWNER MAILING ADDRESS: sTREET (33 4'O( S 1 c a 06D F__ "_Li CITY dia STATE ZIP ?E c 6_3 OWNER PHONE: 9 5 $70 ... bi( C ,. OWNER EMAIL: ... ..R .. ... . �..r<.,_ , ,. .. . a.,a._._.,... CONTRACTOR NAME: HD( ,j2 a PC CONTRACTOR ADDRESS: STREET f9 O X ..6 5- - CnY vetZ STATE 04_L ZIP Ci°v CONTRACTOR PHONE: `/ J-ate ( )(3( CONTRACTOR EMAIL:AJlvtstt 4'9(f t a6 (t e(?- vi/ter,CAbK CONTRACTOR LIC.#(REQUIRED)/7 .rs.rly.,..1s.....wp/D66- D66 n_( 9 CITY On F EVERETT BUSINESS LIC.#..Y..rt..QUit pa(D lea m : � n . _ ,...,,_..:,. . __ PRIMARY CONTACT: 0 OWNER ,CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: L/... 7 a??d`c7 xc,2 6:,c.„, l 0--ir 9 CONTACT EMAIL: AGREEMENT:The undersig ticol applicant agrees to comply with all provisions of the Everett Municipal Code Title City of Everett Official Use Only 14 Water and Sewer or suc er rules and regulations now existing or which maybe established from time to FEE time.The applicant further ag -s,as a condition precedent to receiving service that the utilities division shall have �� r—r the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and nonpayment of charges or for any other reasonable cause.l am the owner,or 1 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# RCW and 296.200A W / P �jL�' Q �v fes^ l kU 1&,0 `O3 OwnerlAuthortzed Agent Sig ture Date (Revised 10/1212015)