8613 4TH PL SE 2016-05-31 - Laserfiche WebLink

.. 477 WIC IER / SEWER UTILITY ffTLICATION CITY OF EVERETT PERMITS ES 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: ,66 (•3 i .1 l L' -6,v 2 T— 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? 0 NO 0 YES, FROM TO UTILITY APPLICATION INFORMATION SEWER(check all that apply) WATER(check all that apply) tr DE 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) 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: " LT c LX ''VCvi;kt TENANT NAME(If Commercial):p,rV t~-e- AresG✓It`1ie.5 OWNER MAILING ADDRESS: sTREEr - CITY � Si TE ZIP OWNER PHONE: O L.13''L-1 (p'Z' OWNER EMAIL: Ctj A,VV11 -V `..LA---Ci —S CONTRACTOR NAME: nu ecus M+C _, �. • CONTRACTOR ADDRESS: STREET 801k qts . ` 9Q"� cr'Y -gV�'.K ,) -- get-a--8 STATE �, ZIP '///�`n-_(.� CONTRACTOR PHONE: 42_s----Lt 1—O I�NTRACTOR EMAIL: �4 ipt_f4 /1 t(� Le_c_g& nC""l.=114,l / CONTRACTOR LIC.#(REQUIRED): 4E4 mob CITY OF EVERETT BUSINESS LIMAREQUIRED): ©SSS'"3 PRIMARY CONTACT: ❑OWNER ONTRACTOR 0 OTHER(Please Specify) CO?tkTACT NAME: CONTACT PHONE: 4-2-7--- S7-- Q tz-3 CA/e,11 !V"-I lQ , CONTACT EMAIL: �q 4 pl, 4 1a i �av2 / AGREEMENT..The undersigned applicant agrees to_comply with all provisions of the Everett Municipal Code Title a,of Everett Official Use Only 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to FEE IP time. The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have the right at any time without notice,to shut off or turn on the water supply for repairs,construction,and 4Pv30 ea nonpaymen • arges. for any other reasonable cause.I am the owner,or I am authorized by the owner of this , properly t. the w,rk for which application is made,and I comply with the State Contractors Law 18.27 PERMIT# RCW and'•• I ACI -vii.�p►'�h.v . i.ot to . U l( )13 t� Owner/Av orized Agent Signature Date (Revised 10/12/2015)