1416 23RD ST 2022-03-02 - Laserfiche WebLink

WIPER I SEWER UT L Y • LCATOIN "111144.,%C----A CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, VVA 98201 (P) 425-257-8810 I FAX 425-257-8857 I (E) everetteps@everettwa.gov I www.everettwa.gov/permits I PROJECT SETE I;NFORMIATION l (�Vl 1S- PROJECT ADDRESS: -� IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL 0 INDUSTRIAL CHANGE OF USE? i NO El YES, FROM TO UTILITY APPLECATi I O Ft REVIATBOL _{ SEWER (check all that apply) WATER(check all that apply) i SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION El SIDE SEWER ALTERATION ❑COMPLETE SERVICE ❑ METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: ❑ INSTALL BACKWATER VALVE(outside the building) ❑ SFR I ❑ SIDE SEWER CAP-OFF ❑ MULTI-FAMILY-#OF UNITS: O SIDE SEWER RECONNECTION ❑ 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. ❑ IRRIGATION: 3/4", 1", 2", OTHER: I ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑ FIRE: 1", 2", 4", 6", 8", OTHER: SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER ❑ DOMESTIC/FIRE COMBO: 1", 2", OTHER: SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. CON ET ACT E FO"If iAT➢*N OWNER NAME: Oil ( 1 Jt )h t �� TENANT NAME (If Commercial): OWNER MAILING ADDRESS: STREET CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: V 1tk P 1, k Y \l /� CONTRACTOR ADDRESS: STREET Y 'i VI iirelY CITY STATE WA' ZIP ,5 A��,��g CONTRACTOR PHONE: ' . I l p Oi'2� CO TRACTOR EMAIL:�IlViy►b1 1 IC 1®A •�.(.,�VI/€ CONTRACTOR LIC.#(REQUIRED): it )� I' _ l i rb CITY OF EVERETT BUSIN LIC.#(REQUIRED):) 0 51 We PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: L,L?.. ?�' 2, .. 9 6121 afkl(j116 C4 1 CONTACT EMAIL: /� /,�i�(1/Avi jy 1 1 to 'l0I M I VVL •elp, AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal dode Title City of Everitt Official Use Only 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to F E E time. The applicant further agrees, a con i. precedent to receiving service that the utilities division shall have the right at anyrtie,w. t notic ,to shut off o turn on the water supply for repairs,construction,and4' �., nonpayment 9f ch r s or or an other reasona le cause.I am the owner,or I am authorized by the owner of this property to pa-fora he wo hich applicano is made,and I comply with the State Contractors Law 18.27 PERMIT# RCW and 29 200 WAC i dwner/Authoriz gent Sig ature Date (Revised 10/12/2015)