1919 HIGHLAND AVE 2020-06-17 - Laserfiche WebLink

CITY OF EVERETT PERMIT SERVICES 1 3200 CEDAR STREET, EVERETT, WA 98201 Fi 8857 E everette s@everettwa.gov [ www.everettw . viRl�p P)425-257--8810 � FAX 425-257 � ( ) p r PROJECT SITE INFORMATION PROJECT ADDRESS: I q 1d'l 11,'e s1>'ll)( AVe., cdY-R'e't-1-• 1/-'l ' l P7O 1 IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: EISFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? 1St NO 0 YES, FROM TO UTILITY.APPLICATION INF a RMATION _ SEWER(check all that apply) WATER(check all that apply) ❑SIDE SEWER REPAIR Yl.NEW WATER SERVICE INSTALLATION ❑ SIDE SEWER ALTERATION I COMPLETE SERVICE 0 METER ONLY X NEW SIDE SEWER INSTALLATION SERVICE/METER USE: ❑ INSTALL BACKWATER VALVE(outside the building) A 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 A 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: A)o'Ikin Cot pile l Grein(j i3Y (Uv TENANT NAME(If Commercial): AVO\ OWNER MAILING ADDRESS: STREET 1 9 t---7 V+;9t 1`In dl Ave, CITY EVr ,CC*r' STATE 1,//4 ZIP 1 q--to 1 OWNER PHONE: OWNER EMAIL: �.. 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: CONTACT EMAIL: AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title City of Everett Official 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, 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 a!other reasonable cause.I am the owner,or I am authorized by the owner of this roe to erform th< ork f. which application is made,and I comply with the State Contractors Law 18.27 p p ,�, p PERMIT# 1 a�- RCW and� 900, :'C _-- - --e._ i 7/2/7/ u ' _ go(", Owner/Authorized Agent Signature Date (Revised 10/12/2015)