4413 GRAND AVE 2020-05-07 - Laserfiche WebLink

WATER , SEWER UTILITY AP L,ICATI 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: LI Lk 1 9O GrAink/ IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ID INDUSTRIAL CHANGE OF USE? NO 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: XINSTALL 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 OWNERNAME: (v <LLt CO TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: IA'A' Ptimvtifi yF CONTRACTOR ADDRESS: STREET Y CITYeAccreit STATE WA, • ZIP 012AIkl'oi� l i 11 CONTRACTOR PHONE: � CONTRACTOR EMAIL: `�V'��-'-` 4 AMA CONTRACTOR LIC.#(REQUIRED): P CITY OF EVERETT BUSIN LIC.#(REQUIRED) PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR ❑OTHER(Please Specify) CONTACT NAME: • CONTACT PHONE: LL-17,S-N) 2S y g,1 r' 6 Pt 1 k, CONTACT EMAIL: A I Whit,iyD ( I C " AlO I • AGREEMENT: g The undersigned applicant agrees to comply with all provisions of the Everett Municipal ode Title \-,1 City of Everitt e Official Use Only 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to FEE 4 w time.The applicant further agrees, a con.i'''n precedent to receiving service that the utilities division shall have er'y the right at any ' e,w" . t notice,to shut off o,turn on the water supply for repairs,construction,and v --'' nonpayment char.-s or or an other reasons'le cause.I am the owner,or am authorized by the owner of this property top-' or he wohich applicatio is made,and I comply with the State Contractors Law 18.27 PERM RCW and 29:200 A WAC t ' u 1T1o_ot ' OwnerlAuthoriz-7•gent Sig ature Date (Revised 10/12/2015)