2410 CLEVELAND AVE 2020-05-07 - Laserfiche WebLink

00111111_, , OVATE / SEWER UTILITY APPLICATION 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/perhnits PROJECT SITE INFORMATION PROJECT ADDRESS: Iii l 0 bt 4 tAGVV A{!v IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: OCOMMERCIAL ❑INDUSTRIAL CHANGE OF USE? Itif 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: 13 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: Viya1/`1/W 4a p.2____ TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET L Lj f p cA,e,ve,1 o,V Yd et CITY -W (/ J STATE WA • ZIP el 8 20 1 OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: ' P CONTRACTOR ADDRESS: STREETegtretWi 1 V . CITY eAJ ,rt(1" STATECITY , STATE WA 0 1 ZIP ot 0416:6 ..) CONTRACTOR PHONE: LJ 1 TR ) CO ACTOR EMAIL: 4114/ ►[lit l �( _ 0114A44 IICAM CONTRACTOR LIC,#(REQUIRED) L d CITY OF EVERETT RUSILIC.#(REQUIRED): 4 (e PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: • CONTACT PHONE: (..1-11,'� 1 2 ---9(42.1 Ase-116 1►�n`P`i VA,-111.---- CONTACT EMAIL: � /III I 14414 Id I Il. 2f11011/444( it-� J,,, AGREEMENT-The undersigned applicant agrees to comply with all provisions of the Everett Municipal 4.de Title City of EveOfficial 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., precedent to receiving service that the utilities division shall have O•00 the right at any " e,w' . t notice,to shut off o,turn on the water supply for repairs,construction,and nonpayment. ch,' •-s or or an other reasons le cause.I am the owner,or I am authorized by the owner of this property to p- or he wo hich applicatio is made,and I comply with the State Contractors Law 18.27 PERMIT jt and 29:200, WAC ►� d� 20t U 101 Q'1 - OH5 caner/Authoriz .. gent Siglature Date (Revised 10/12/2015)