3004 23RD ST 2016-06-02 - Laserfiche WebLink

WATER / SEWER UTILITY APPLICATION I: -/ 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: 3 Wll 23rd cS' IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ODULEX ❑MULTI-FAMILY-#OF UNITS: I:KOMMERCIAL ❑INDUSTRIAL ' CHANGE OF USE? 0 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 0 SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY 0 NEW SIDE SEWER INSTALLATION SERVICE METER USE: 0 INSTALL BACKWATER VALVE(outside the building) 0 SFR ❑SIDE SEWER CAP-OFF 0 MULTI-FAMILY-#OF UNITS: ❑SIDE SEWER RECONNECTION ❑ COMMERCIAL MULTIPLE DOMESTIC WATER SERVICES REQUEST IJ.ATER SERVICE TYPE/SIZE: (circle desired size) ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR 0 DOMESTIC: 3i4". 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: t". 2". 4". 8". 8", OrHER: 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: l l)'Ch C,08 Rby'Qc, TENANT NAME (If Commercial): Ch urCj' Pir'c ,QGy OWNER MAILING ADDRESS: 9Tt__-; 0() 'h Ever(' ' . i WA- , q,E2 OWNER PHONE: ti.25-.2 -56 9 i/ OWNER EMAIL: CONTRACTOR NAME: nn r. ec-r T (ufrib� f tkoki n 5 CONTRACTOR ADDRESS: ;rot_• 20a� it (D-fnv rlT,. ,,E,4'�� '..r LLD 4- .'w q CONTRACTOR PHONE: 20Le 730 Q 7x34 CONTRACTOR EMAIL: cha roar'& l l`- m r rpo r eo .CGS CONTRACTOR LIC.#(REQUIRED): Meg n P 0221' CITY OF EVERETT BUSINESS LIC.#(REOUIRED): 03 PRIMARY CONTACT: 0 OWNER 60 CONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: 2.O( ' lD`l 1 2' i'7 chayi2s1k. UAndgrem CONTACT EMAIL: akar ro v Se _caw) A:;REEMErN I the undersigned applicant agrees to compry with ail provisions c'the Everett iL4unicipol Cotte f,t:e Cary of Everett.'iuiaa:Use Only 14 Water and Sewer or such other rules and regulations now existing or which nsuy be established from time to F E E time. The applicant further agrees.as a condition precedent to receiving service:hat the utilities Division snail have the right at any time.without notice.to shut°Nur tum on the water supply tor repairs.Cow'struCtiun anu4P /n�J//q,J nonpayment of charges or for any other reasonabe cause.I am:he owner ori iris authonzyi by:he owner of tins `�v 9 pi-.e,y . erform me work for win appilcaLpn is made and I comply.rye Me State C ontractors Law t8 C' PERMIT# .,.1 l.� 1..A .4 /' 6 5 Own Authorized Ages, ture , t)a:I> Rim ..Pat 'Q,+?,'-Of:;;