1609 5TH ST 2020-05-21 - Laserfiche WebLink

WpR OLT / SEWER UTILITY 'LICATION 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:160cI 7 5 " S � Gdc _0 Lie; lc4g TAeP : QoL(96. t3` io(20J IF APPLICABLE: El OUTSIDE CITY LIMITS G- BUILDING AREA a'-00 SF ❑ LOT# a BUILDING TYPE: *FR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? El NO IV-YES, FROM °r t...tAf(<- eh /U1I-cAw TO NC-1,,) f UTILITY APPLICATION INFORMATION SEWER (check all that apply) WATER (check all that apply) ❑ SIDE SEWER REPAIR *NEW WATER SERVICE INSTALLATION El SIDE SEWER ALTERATION PICOMPLETE SERVICE (_I METER ONLY NEW SIDE SEWER INSTALLATION SERVICE/METER USE: IZ INSTALL BACKWATER VALVE(outside the building) Xi SFR ❑ SIDE SEWER CAP-OFF 0 MULTI-FAMILY-#OF UNITS: O SIDE SEWER RECONNECTION 0 COMMERCIAL MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE: (circle desired size) ❑ IAM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR Al 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 El 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: G(LICA TENANT NAME (If Commercial): OWNER MAILING ADDRESS: STREET S50 At...v)Zf?7U fLV4 city STATE 1-4 - ZIP '14r"4- OWNER PHONE: 9?-5-111.1.-0141— OWNER EMAIL: Kn t`L,a - t°{ L-10GdN6T/Ci/ VET- CONTRACTOR NAME: CONTRACTOR ADDRESS: STREET CITY STATE ZIP CONTRACTOR PHONE: CONTRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED): PRIMARY CONTACT: OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: A ! 1 CONTACT EMAIL: AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to time.The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and nonpayment of charges or for any other reasonable cause.I am the owner,or I am authorized by the owner of this property to perform the work for which application is made,and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. City of Everett Official Use Only PERMIT# 7 34 U Q Stol— ®Z?/ Owner/Authorized Agent Signature Date (Revised 9/23/2016)