3505 UPLAND AVE 2020-09-08 - Laserfiche WebLink

#41p. WATER SEWER UTILITY APPLICATION 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 I N F O R M A TIO N PROJECT ADDRESS: e3505 vplaftd NE. IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# a BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL DINDUSTRIAL CHANGE OF USE? ❑NO ❑YES, FROM TO UTILITY APPLICATION INFORMATION SEWER(check all that apply) WATER(check all that apply) 0 SIDE SEWER REPAIR KNEW WATER SERVICE INSTALLATION 0 SIDE SEWER ALTERATION 0 COMPLETE SERVICE KMETER ONLY ig NEW SIDE SEWER INSTALLATION SERVICE/METER USE: ❑ INSTALL BACKWATER VALVE(outside the building) SirSFR ❑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 .DOMESTIC: 0 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: /k iflE, HQMF$ 1.1-0—. TENANT NAME(If Commercial): OWNER MAILING ADDRESS: sTREer / I/1/ ^�..� ISD c : <SE G�/ /L CITY SnoI cO/Yt lJ/t. STATE Ain ZIP q(�Z la OWNER PHONE: '5 qo 3--©O 3 ! OWNER EMAIL: CONTRACTOR NAME: ownFiji • CONTRACTOR ADDRESS: STREET CITY STATEn ,, ss ZIP , CONTRACTOR PHONE: CONTRACTOR EMAIL: aeln&Jdi EC53yrL&It 17l CONTRACTOR LIC,.#(REQUIRED): CITY OF EVERETT BUSINESS LIG.#(REQUIRED): PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME:� CONTACT PHONE: Lb?S — 3--QS39 Shi(oh cockt CONTACT EMAIL: act/Edo/oh @QmiJf tcmin. AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title IUf 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 t 550♦ nonpayment of c - f-s o for any other rea • able cause.lam the owner,or lam authorized by the owner of this property to -rforr; -AI!. for which-,;tion is made,and I comply with the State Contractors Law 18.27 PERMIT# 4RCWa • :46...A AC. // --2p/4 U MO —03 3 Own- uthorized Agent Signature Date (Revised 10/12/2015)