2717 MAPLE ST 2016-05-25 - Laserfiche WebLink

OLT WI =R / SEWER UTILITY I- 3LICATION 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 , "4` f P 04:0.6 7E}INFORIIKATION PROJECT ADDRESS: ,2 J 7 Wl i4-? 0 '7l,...,;1-G.„--,/,O". ffG o i IF APPLICABLE: 0, OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT# EIS-FR-DETACHED BUILDING TYPE: SFR-DETACHED ❑SFR-ATTACHED ❑DULEX 0 MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? 0-NO ❑ 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 I5 SIDE SEWER CAP-OFF ❑ 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 ❑ 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 ❑ 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. /- C.ONTACT$NFQRMATION :.': OWNER NAME:�ilett- �!A-r 1!L d hiNIA16 TENANT NAME (If Commercial): OWNER MAILING ADDRESS: STREET / -[o o Dfin N yt /E ( �j / ,-j CITY �fpiILL eF'. STATE (j-)� ZIP9Sr&I .2— OWNER OWNER PHONE:�Z5 6/0 -'45I2 l OWNER EMAIL:?? tx e fou % t-c , Ce9fN--- CONTRACTOR NAME: 18 +µ5% C-j/c. 4. 5c�4; c t-? l'( CONTRACTOR ADDRESS: STREET 3t>3 91I-We—/St C 5`6 ,5-3 CITY Mite- / t r-Lie.I�5 STATE Vs)* ZIP 9 ' CONTRACTOR PHONE:4/may 3-Eg' 7 O CONTRACTOR EMAIL:?iCaWtsNC ngi cz.te')"rd.it l t ui ee'5( CE), - CONTRACTOR LIC.#(REOUIRED):?t4isC, 965 tq\,k CITY OF EVERETT BUSINESS LIC.#(REQUIRED): PRIMARY CONTACT: ❑ OWNER L�CONTRACTOR ❑ OTHER(Please Specify) 050 Ir' 7 CO TACT NAME; CONTACT PHONE: f Z5 _jt2--Ty L J-K_ t c`1 c -C CONTACT EMAIL: (aii4 €),,yva(/✓`l:%c:rl d\//y'r c.(C�S.C'-E-t/A 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 F F E time. The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have _-?7 the right at any time,without notice,to shut off or turn 1;2 on the water supply for repairs,construction,and l O l nonpayment of charges or for any other reasonable cause.I am the owner,or I am authorized by the owner of this prop y to erfo e work for which ap lication is made,and I comply with the State Contractors Law 18.27 PERMIT# RCW nd 96.20 A WAC. ll/z f// S_ U ICS 1 ( _ o (J 0 0 ner/Authorized Agent Signature Date (Revised 10/12/2015)