3316 GRAND AVE 2020-03-16 - Laserfiche WebLink

4alaiOFATE / SEWER UTILITY APPLICATION W CITY EVRE 3200 CEDAR STREETETT, EVERETTPERMIT , WSERVICES201 . A 98 (P)425-257-8810 I FAX 425-257-8857 1 (E) everetteps@everettwa.gov 1 www.everettwa.gov/permits PROJECTpSITE INFORMATION PROJECT ADDRESS: /CA t.0 & Oi l) IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? LNO ❑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: 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 0 DOMESTIC/FIRE COMBO: 1", 2", OTHER: SINGLE OWNERSHIP. FILL.OUT REVERSE SIDE OF THIS FORM. CONTACT INFORMATION OWNER NAME: AD , 0..,b1,J0..,b1,b 100 TENANT NAME(If Commercial): OWNER MAILING ESS: STREET �j Q'y a„lit6• CITY V STATE W, ZIP 61,?2 1 OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: 14 Pr V, CONTRACTOR ADDRESS: STREETegtra t �� • CITY STATE WA . ZIP ot 0 2,66 CONTRACTOR PHONE:uti.). LA 'st-012 CO TRACTOR EMAIL:AlAliAlviiM lornit1 lic ®A o I i CONTRACTOR LIC.#(REQUIRED): PA + c CITY OF EVERETT BUSIN LIC #(REQUIRED)):/ ® L r PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME:_AME: . CONTACT PHONE: (,Li J Z'b"'(19,Z� e . /',(J( " W' '\ \ CONTACT EMAIL: /� / I` ,[M�.idr 1 , 10a1y mi • AGREEMENT.:The undersigned applicant agrees to comply with all provisions of the Everett Municipal 4.de Title City of Evert 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, - a con.i precedent to receiving service that the utilities division shall have L 3© v the right at any ' e,IV • t notic to shut off o turn on the water supply for repairs,construction,and l-+' �� nonpayment• ch-r.-s or or an.•other reasonat le cause.1 am the owner,or am authorized by the owner of this property top- or he wo hich applicatio is made,and I comply with the State Contractors Law 18.27 PERMIT#,-% RCW and 29;200 A WAC t ' U t O k r�1cz Owner/Authoriz gent 5ig'ature Date (Revised 10/12/2015) V