5019 W VIEW DR 2016-05-27 - Laserfiche WebLink

OiSerr 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 INFORMATION PROJECT ADDRESS: 5-01`1 VO • N iem> �( t evu L.J/- 414Z0.5 IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? ❑NO 0 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 ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: ❑ 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 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: '1414e.- 61So+,, TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET ,SOIi W. \I.g..•3 .Ir cmiE.- veldt' STATE ij/ ZIP 9 48 Zd 5 OWNER PHONE: I{Z'S • .b.:4/- I1 OWNER EMAIL: CONTRACTOR NAME: elAA .•J es 4- -?1...›to...10%'^o� M I_ ( ,; . 1"`o,ri$ CONTRACTOR ADDRESS: STREET Zak ,5 � J tcr6K- 5� CITY 5e4• STATE Pl. A� ZIP l G %(.O(.. CONTRACTOR PHONE: ?LC*-93 Z' nil CONTRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): SOOT Fl t�f 0-7 I G Co CITY OF EVERETT BUSINESS LIC.#(REQUIRED):O?ct636 PRIMARY CONTACT: ❑OWNER tit CONTRACTOR MOTHER(Please Specify) 1i z tAa/45 (ZO(o)W ii- 4LtgO CONTACT NAME: CONTACT PHONE: CONTACT EMAIL: AGREEMENT:The undersigned applicant agrees to comply with all provisions of the erett Municipal Code Title City of Everett Official Use Only 14 Wafer and Sewer or such other rules and regul- .now existing or which m- .:established from time to FEE time. The applicant further agrees, .'. cond'%• p ..-dent to receiving serv''" - the utilities division shall have i j� the right at any time,without no ' -,to sh , off o tum on -water supply • ..airs,construction,and '°- nonpayment of charges or fo - y othe• -a.• able c ,se.I a, he owr. • 1 am authorized by the owner of this property to perform the w,; •r whi a'4catio• made -F. corn. h the State Con ctors L 18.27 PERMIT# RCW and •6.200A W;/ / `/' 3 z 4 U U.O / t ,7 A /�..�, • � I 0!'mer/Authorized Agent Signet Date (Revised 10/1212015)