2602 BROADWAY 2020-05-07 - Laserfiche WebLink

00104V WATER i SEWER UTILITYAPPLICATION 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 SITEtINFORMATION ' -. PROJECT ADDRESS: 2 co 0? "By"O .k Ato , IF APPLICABLE: 0 OUTSIDE CITY LIMITS DJBUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX DMULTI-FAMILY-#OF UNITS: ❑COMMERCIAL [INDUSTRIAL CHANGE OF USE? d.f ❑YES, FROM TO UTILITY APPLICATION INFORMATION SEWER(check all that apply) WATER(check all that apply) ❑SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION ❑SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: NSTALL BACKWATER VALVE(outside the building) 0 SFR ❑SIDE SEWER CAP-OFF 0 MULTI-FAMILY-#OF UNITS: 0 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 ❑.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: � oPl ilCONTRACTOR ADDRESS: STREET l GJ ,ICA, • CITY STATE a, • /ZIP O CONTRACTOR PHONE:(jJ ••) 1g)iil' O12') CO TRACTOR EMAIL:0 0, ,k4 L bl�, ' 1 2i'11 O " Wvi• ,ielim CONTRACTOR LIC.#REQUIRED: IA CITY OF EVERETT BUSINI LIC.#(REQUIRED): Q PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: • CONTACT PHONE: Ci�!/Jj 9�.... 7-1921 �/' 6 1► ��`� 0,414----- CONTACT EMAIL: /� /Y X111 VVi�.II f I ic �v am/�,i .0440 AGREEMENT. The undersigned applicant agrees to comply with all provisions of the Everett Municipal CodepTitle City of Everbft 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.iti•n precedent to receiving service that the utilities division shall have aV the right at any ane,w,j1 . t notic-,to shut off o turn on the water supply for repairs,construction,and 41 .B vi nonpayment ch r s or•or an. other reasons le cause.I am the owner,or I am authorized by the owner of this property to p orar) he wo •r. hich applicatio is made,and I comply with the State Contractors Law 18.27 PERMI RCW and 29 200 C u \ ' O�� Owner/Authoriz-..)Agent Sig'ature Date (Revised 10/12/2015)