1021 EDWARDS AVE 2021-02-19 - Laserfiche WebLink

TER / SEWER UTILITY PPLICATION CITY OF EVERETT PERMIT SERVICES stsf . 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: t b Li , iiiiivounti,.4Aitivd. IF APPLICABLE: ❑OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY#OF UNITS: OCOMMERCIAL ❑INDUSTRIAL_ CHANGE OF USE? NO ❑YES, FROM TO UTILITY APPLICATION INFORMATION SEWER(check all that apply) WATER(check all that apply) ASIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION ❑SIDE SEWER ALTERATION 0 COMPLETE SERVICE ❑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 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: .6�Kirt. 4°1117F1N),•'Vin_ k TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET 1,b21 AWo 'd,J Ct t ' '}� /� f CITY STATE 1�I 1(/t ZIP K/ 4 OWNER PHONE: OWNER EMAIL: VVV�� CONTRACTOR NAME: 4 P' PimiA CONTRACTOR ADDRESS: STREETeerareit ' Igh* a ►ht&.} CITY STATE Wei,/� .'A ZIP ��/a/�eV* CONTRACTOR PHONE:l Y[ � o"'O12 ) CO TRACTOR EMAIL:ait t tai ti lir I �/ . 1 O y Vi9 i 401144 CONTRACTOR Lie.#(REQUIRED): a) 1,004.16L CITY OF EVERETT BUSIN LIC.#(REQUIRED): PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: . CONTACT PHONE: , ) 1 2b-q 92,1 Niei16 Vol,I, Irtet.--- CONTACT EMAIL: rA / �`.'IAMA IA i I C 6 U Mkt 1 a 0 AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal 4.de Title City of Ever t 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 r' precedent to receiving service that the utilities division shall have 4,0 the right at any ' e,w' b t notic<,to shut off o turn on the water supply for repairs,construction,and 430 nonpayment ch-r.,-s or or an other reasona le cause.l am the owner,or am authorized by the owner of this property to p- or he wo hich applicatno is made,and I comply with the State Contractors Law 18.27 PERMIT# yVand29;2o0• WAC►� U 2C�o 2— o2.aner/Authoriz•:1,'gent Siga Lure Date (Revised 10/12/2015)