2403 MAPLE ST 2020-05-22 - Laserfiche WebLink

A ,AT / SEWE a UTILITYAPPLICATION -- CITY OF EVERETT PERMIT SERVICES 4r� 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: int Ci: IF APPLICABLE: 0 OUTSIDE CITY LI 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-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) 17k4SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION ❑ SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY • O NEW SIDE SEWER INSTALLATION SERVICE/METER USE: O INSTALL BACKWATER VALVE(outside the building) 0 SFR 0 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. 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: 4'v �' f pTENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET LaID` i• n ) CITY e1V1IIr V tc STATE \AM OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: L , m4 reir CONTRACTOR ADDRESS: STREET 1 \1114311V4,144/4 CITY STATE WA • P� j /ZZIIP �, CONTRACTOR PHONE: , \) T-OrA CO TRACTOR EMAIL: 1 )111,, lc, G -fl O1W ,j tialil CONTRACTOR LIC #(REQUIRED) V .A. t I . CITY OF EVERETT BUSIN LIC.#(REQUIRED). 0515514, ,N, PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 0 OTHER(Please Specify) • CONTACT NAME: . CONTACT PHONE: L14 � 122 '�Ti 2,1 r 1 `6 � f CONTACT EMAIL: /A / 1i 1 VI/I✓✓✓�✓1. i ll T1s 1O I • AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal•ode Title City of Everbtt Official Use Only A g AP 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 cons"An precedent to receiving service that the utilities division shall have O (�J the right at any " e,W . t notic,to shut off o turn on the water supply for repairs,construction,and ../ nonpayment•f ch.'r.-s or or an other reasona,le cause.lam the owner,or am authorized by the owner of this ii property top- or he wo • hich applicatio is made,and I comply with the State Contractors Law 18.27 W PE IT# � RCW and 29:200' C • U hO}V L. 0t •wner/Authoriz-. •gent Sig ature Date (Revised 10/12/2015)