2912 NASSAU ST 2020-05-07 - Laserfiche WebLink

eV T , SEWER UTILITY APPLICATION P '►' CITY OF EVERETT PERMIT SERVICES �t 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„ I, PROJECT ADDRESS: .-" ttL. Y\a.,t,s . 6J --. IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX DMULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? 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 O NEW SIDE SEWER INSTALLATION SERVICE/METER USE: INSTALL 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. ❑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. I ``�� CONTACT INFORMATION OWNER NAME: UQ'v'i l JAI\ i t JA1 TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: ()talk CONTRACTOR ADDRESS: STREETlel ' \40114Agilleto, firo• CITY - STATE VIM, o ZIP 41,02 i�3 biti. ®gCONTRACTOR PHONE: CO TRACTOR EMAIL �) CONTRACTOR LIC #(REQUIRED): LAIt . CITY OF EVERETT BUSILIC #(REQUIRED)1 65' PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: . CONTACT PHONE: LH' 12,b— •1 1 21 ril6AtAcit1 Y CONTACT EMAIL: A / ► 11 1,1gl l lc A10 l oacw A undersignedapplicant The a licant agrees to comply with all provisions of the Everett Municipal 4 ode Title City of Evert Official Use Only 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 coni",n precedent to receiving service that the utilities division shall have 4+30 the right at any ' e,w' t notic to shut off o turn on the water supply for repairs,construction,and nonpayment r ch,r.-s or or an other reasona cle cause.I 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 PERMI T R)(I CW and 29:•200 WAC ' - u (6 O/ 0\7, _ ', v1 wner/Authoriz- \gent Sig'ature Date (Revised 10/12/2015)