2014 GRAND AVE 2020-05-22 - Laserfiche WebLink

WI ER I SEWER UTILITY i PLICATION 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: , Q1 q Cliala_ Ate IF APPLICABLE: ❑ OUTSIDE CITY LIMITS 0 BUILDING AREA SF ❑ LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX OMULTI-FAMILY-#OF UNITS: OCOMMERCIAL ❑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 ❑ COMPLETE SERVICE ❑ METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: INSTALL BACKWATER VALVE(outside the building) 0 SFR ❑ SIDE SEWER CAP-OFF 0 MULTI-FAMILY-#OF UNITS: ❑ SIDE SEWER RECONNECTION ❑ COMMERCIAL MULTIPLE DOMESTIC WATER SERVICES REQUEST • WATER SERVICE TYPE/SIZE: (circle desired size) ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR ❑ 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 ❑ 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. 11 CONTACT INFORMATION OWNER NAME: cRt�'yI ((, ,CjGiI 1 TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: ( h2f te_ cwrxkt- �C�4(6� ,K-t ' `vcpb 4- cl l`s 1)10,1415CONnTRACTOR ADDRESS: STREET (D-�I(ovl�+T,1 VL { �/� (]�,D7 //r�� d'irAsV1s Lie_ CITY STATE "V 0,_ ZIP q lJ CONTRACTOR PHONE: pj s 77O CONTRACTOR EMAIL: C A� VCITY OF EVERETT BUSINESS (R ): CONTRACTOR LIC,#(REQUIRED) F:13-7 po� LIC.# EQUIREDm_.,_s,.. PRIMARY CONTACT: :: OWNER 0 CONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: CUCS__ V-7G,_0()--70 rir\vsD Gam Jf , is✓"0 CONTACT EMAIL: Npyv( ( ') `/lip6i1r —plt,,A.5, ( ,,n 1AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title City of Eett 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, as a condition precedent to receiving service that the utilities division shall have * 1` Ui the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and y nonpayment of charges or or any other reasonable cause.I am the owner, or I am authorized by the owner of this prop: . to perform the wo'/k for which application is made,and I comply with Ithee�State ContractorsCotrLaw 18.27 PERMIT (y�#,� r /p R a 6.200A • t !h\ o fbl ire 1 C Owner/Author -: .gent Signature Date (Revised 10/12/2015)