2017 GRAND AVE 2020-05-08 - Laserfiche WebLink

j"_ . WATER / SEWER UTILITY APPLICATION CITY OF EVERETT PERMIT SERVICES vt 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: )—O fl a /Lt, IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL 0 INDUSTRIAL CHANGE OF USE? 'YiNO ❑YES, FROM TO UTILITY APPLICATION INFORMATION SEWER(check all that apply) WATER(check all that apply) XSIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION 0 SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: 0 INSTALL BACKWATER VALVE(outside the building) 0 SFR 0 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: TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: 1,111- P,Immiotii.eAttivit CONTRACTOR ADDRESS: STREET I Y h Vtt . CITY STATE • ZIP ',0 CONTRACTOR PHONE:!Y[ � Qyt 012 CO TRACTOR EMAIL: f\UM tovtbi yin 1 le, Opivai I am ,.f5t1 b CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSIN LIC.#(REQUIRED): PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: • �/'/j CONTACT PHONE: (✓�!/. ��-9921 VVViLL✓ �ti l 1(�1" � CONTACT EMAIL: /i I VV}�VI.VJ irtlI is z,410/1444A( . /.IW1 AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal de Title City of Ever Official Use Onlynl 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to FEE 1} time. The applicant further agrees, .- a con i" precedent to receiving service that the utilities division shall have I, 00 W the right at any " e, • t notice,to shut off o turn on the water supply for repairs,construction,and , nonpayment• ch:r•-s or or an other reasona le cause.I am the owner,or I am authorized by the owner of this property to p or he wohich applicatio is made,and!comply with the State Contractors Law 18.27 PERMIT# RCWand 29%200 C � .� vie) nU 1q b(o—N6 1 _OCe V2-0 Owner/Authoriz•1,gent Sig lature Date (Revised 10/12/2015)