2414 MAPLE ST 2020-12-23 - Laserfiche WebLink

Aiw- WATER / SEWER UTILITY APPLICATION �^' 4` 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:Vj'it4 g"�;IF APPLICABLE: ❑OUTSINit LIMITS ❑ BUILDING AREA SF ❑ LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? NO ❑YES, FROM TO UTILITY APPLICATION INFORMATION SEWER(check all that apply) WATER(check all that apply) ti,SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION ❑ SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: U INSTALL BACKWATER VALVE(outside the building) 0 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: ❑.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: J�VtA 4? TENANT NAME(If Commercial): OWNER MAILING ADDRESS: NVSTRREE`T r. CITYttAl•VrtitSTATE v V y` ZIIgt KILO I OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: P J 1 ► P, k •�Mw\ CONTRACTOR ADDRESS: STREET d(D L I �rh VgA, • CITY STATE \AM • ZIP 4, CONTRACTOR PHONE:U4!�� Q! Ot23 CO TRACTOR EMAIL:Yam" siV Ali a[lit1 YS V. 1®1M44• SCOW. CONTRACTOR LIC.#(REQUIRED): �L t CITY OF EVERETT BUSILIC.#(REQUIRED): D PRIMARY CONTACT: ❑OWNER ❑ CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: • CONTACT PHONE: LLOSM I Z' q q 2-fii CONTACT EMAIL: A , di/141414ml ( ,c ,,,n0 AGREEMENT: The undersigned applicant agrees to comply with all provisions of the Everett Municipal a•de Title City of Everitt Official Use Only 14 Water and Sewer or such other rules and regulations now existing or which maybe established from time to FEE. time.The applicant further agrees, a con.' , precedent to receiving service that the utilities division shall have 43E) pi2,...the right at any ' e,w' . t notice,to shut off o turn on the water supply for repairs,construction,and nonpayment•f ch.,r•-s or or an'otherreasona,le cause.I am the owner,or am authorized by the owner of this property top--or he wo .•r; hich applicato is made,and l comply with the State Contractors Law 18.27 PERMIT# $,Vand29200A WAk.0 wo ner/Authoriz- I♦;gent Sig,ature Date (Revised 10/12/2015)