3210 LOMBARD AVE A 2022-03-01 - Laserfiche WebLink

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: "7 10 thmkxurc( VA IF APPLICABLE: 0 OUTSIDE CITY LIMITS ❑ BUILDING AREA SF 0 LOT# 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) SIDE 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 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: 1101,, A c b'Or-5 TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET '2.t.0 mat ar e, . CITY6VArt,f1- STATE Vtgl ' ZIP 61 g 2'0 I OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: d ► f 4 u mtei CONTRACTOR ADDRESS: STREET ( 1 libilY4414,1L.,00 . 11Y ��t� CITY STATE 1 A AA . ZIP 't 0 CONTRACTOR PHONE:Ui-�gla---01•24 CO TRACTOR EMAIL: �I t %4Il�Yi ' y1® mo +WCONTRACTOR LIC.#(REQUIRED): )10 It r CITY OF EVERETT BUSIN LIC.#(REQUIRED): ®515.574, PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: !0'3*3.) 2 '1 b "121 / 6 9 l\ yg CONTACT EMAIL: /� I i j 01 I �C-244 �0 a AGREEMENT-The undersigned applicant agrees to comply with all provisions of the Everett Municipal 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 I"n precedent to receiving service that the utilities division shall have (D the right at any . e,w" • t notic.,to shut off o turn on the water supply for repairs,construction, and OD , nonpayment. ch.r..-s or or an otherreasona le cause.I am the owner,or l am authorized by the owner of this property top- or he wo • hich applicano is made,and I comply with the State Contractors Law 18.27 PERMIT# RCW and 29:200' WAC iii )(4\ k ' "" wner/Authoriz-et gent Sig'ature Date (Revised 10/12/2015)