3527 LOMBARD AVE 2020-06-17 - Laserfiche WebLink

WATERI SEWER UTILITY APP UCAT N .--- 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: j q21 I I k'4' � . IF APPLICABLE: ❑ OUTSIDE CITY1LIMITS ❑ BUILDING AREA SF ❑ LOT# BUILDING TYPE: EISFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? I NO El 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 0 COMPLETE SERVICE 0 METER ONLY O NEW SIDE SEWER INSTALLATION SERVICE/METER USE: 13 INSTALL BACKWATER VALVE(outside the building) ❑ SFR ❑ SIDE SEWER CAP-OFF 0 MULTI-FAMILY-#OF UNITS: ❑ SIDE SEWER RECONNECTION El 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 ❑ FIRE: 1", 2", 4", 6", 8", OTHER: SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER ❑ DOMESTIC/FIRE COMBO: 1", 2", OTHER: SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. t CONTACT INFORMATION OWNER NAME: \J[5 ,i'/1 �1t� I I.0 TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET 3t7 1.7 \, 1.al/VA({1()Y-/ �i / I CITY �/t/�e/i (/I STATE w . ZIP D [SCJ l OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: 1e CONTRACTOR ADDRESS: STREET ' 1 V'j S AP5i ,V°/� CITY Ntrell ' STATE vm . ZIP Ci, . j) CONTRACTOR PHONE:Uot.'2,„ 0I ®t CO TRACTOR EMAIL:DLO tuft b� 1 I 196' 'I. o CONTRACTOR LIC.#(REQUIRED): jib Ati CITY OF EVERETT BUSIN LIC.#(REQUIRED): 051 155(c3 PRIMARY CONTACT: 0 OWNER ❑ CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: . CONTACT PHONE: L 612..., 921 OAA,H16 I '' CONTACT EMAIL: �' `) I VV$�lJ I / [ �C �� .I • AGREEMENT.The undersigned applicant agrees to comply with all provisions of the Everett Municipal 4'.de Title City of Everbtt Official Use Only 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to FEE time. The applicant further agrees,$'a con 1"an precedent to receiving service that the utilities division shall have 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.I am the owner,or t am authorized by the owner of this property top or he wo hich applicatio is made,and I comply with the State Contractors Law 18.27 PERMIT# RCW and 29 200' WAC ► � ' -- Date2 « 1902-0 2002;-0 ti OwnerlAuthonz•.. ••gent Sig ature (Revised 10/12/2015)