1802 COLBY AVE 2020-12-21 - Laserfiche WebLink

WATER / SEWER UTILITY APPLICATION viiiiwi - 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: 19) ? OA\ IF APPLICABLE: 0 OUTSIDE CITY LIMIT 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? f.‘1,,,C: ❑YES, FROM TO UTILITY APPLICATION 'INFORMATION h SEWER(check all that apply) WATER(check all that apply) WSIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION ❑SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: O INSTALL BACKWATER VALVE(outside the building) ❑ 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 ❑ DOMESTIC: 3/4", 1", 2", OTHER: MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. 0 IRRIGATION: 3/4", 1", 2", OTHER: O 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. p�,,� CONTACT INFORMATION C OWNER NAME: ) 'm k OZ/lio a 1/00y6 TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET - l k i CITY STATE Vr Vl ZIP Cit20) OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: Y! 6 PlAkiviiiii , CONTRACTOR ADDRESS: STREETetit ' a GJ � / D CITY STATE VJA, s ZIP qeui/ CONTRACTOR PHONE:(Ali) ot ®i2� CO TRACTOR EMAIL: . bl 1 lc, 2/4-1010,444 'CPA CONTRACTOR LIC.#(REQUIRED): ✓ l CITY OF EVERETT BUSINY LIC.#(REQUIRED): ®91 r_ PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: . CONTACT PHONE: LL$ / q Z'�-(1921 Y' 6 /1, 1 YYI. CONTACT EMAIL: A , i) 1 V!/i�.j,' ( C 21410 1mA4,1 oeom AGREEMENT-The undersigned applicant agrees to comply with all provisions of the Everett Municipal I.de Title City of EverAtt 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 " precedent to receiving service that the utilities division shall have W the right at any " e,w . t notic ,to shut off o turn on the water supply for repairs,construction,and - b j — ' nonpayment. char.-s or or an. other reasona le cause.l am the owner,or I am authorized by the owner of this �/ property top- or he wo 6 hich applicanio is made,and I comply with the State Contractors Law 18.27 PERMIT# 7,Vand29200, WACk --. U ‘9 \ -,...01 V nerlAuthoriz `� gent Sig nature Date (Revised 10/12/2015).