4020 GRAND AVE 2020-03-06 - Laserfiche WebLink

"iliP, ATE / SEWER UTILITY APPLICATION _- CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT,WA 98201 . (P)425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov 1 www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: L D t GrAiNDU 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? 12(1? ❑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: TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: A104- J 4 CONTRACTOR ADDRESS: STREET 1_ \PhtilltkiMit, itittioA CITY STATE V , Y ZIP n CONTRACTOR PHONE:U4 AT.O1'3 CO TRACTOR EMAIL:004\ b1 ii// l 106 ®`i CONTRACTOR LIC.#(REQUIRED): L .Ir rt) CITY OF EVERETT BUSIN4 LIC #(REQUIRED) ® �M5 PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR ❑OTHER(Please Specify) CONTACT NAME: . CONTACT PHONE: LH 12,S-16121 j � "I\ '( CONTACT EMAIL: /( )I'M Vl IINLIC anvi I i AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal ode Title City of Evert Official Use Only M g PP 14 Water and Sewer or such other rules and regulations now existing or which maybe established from time to FEE time.The applicant further agrees, a con.+',n precedent to receiving service that the utilities division shall have A s, the right at any ' e,w' . t notic to shut off o turn on the water supply for repairs,construction,and nonpayment ch,r.-s or or an other reasone'le cause.I am the owner,or I am authorized by the owner of this property top- or he wo . hich applcatio is made,and I comply with the State Contractors Law 18.27 PE PERMITS L-'OL7 RCW and 29;200, WAC C lC�j iii 4 . [ caner/Authoriz-' ,gent Sig'ature Date (Revised 10/12/2015)