1415 33RD ST 2016-06-02 - Laserfiche WebLink

OLT WATER / SEWER UTILITY APPLICATION CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P) 425-257-8810 I FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: ILI I15 ,2,2rd IF APPLICABLE: ❑ OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED DIT/' FR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? ❑ NO ❑YES, FROM TO UTILITY APPLICATION INFORMATION SEWER(check all that apply) WATER (check all that apply) Er-SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION ❑SIDE SEWER ALTERATION ❑COMPLETE SERVICE 0 METER ONLY ❑NEW SIDE SEWER INSTALLATION SERVICE/METER USE: ❑INSTALL BACKWATER VALVE(outside the building) ❑SFR ❑SIDE SEWER CAP-OFF ❑MULTI-FAMILY-#OF UNITS: ❑SIDE SEWER RECONNECTION ❑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. ❑IRRIGATION: 3/4", 1". 2", OTHER: ❑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. CONTACT INFORMATION OWNER NAME: mcrL RUl L TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET 114/6 3 rd (S"V 5-ATE 1A) ZIP i 2O 1 OWNER PHONE: 425"' err- •75"7 OWNER EMAIL: CONTRACTOR NAME: mr. tary-A . ' PI u b(nq___ CONTRACTOR ADDRESS: STREET 2n_1 ,S11(66 q (gyp cm 3P�: 44 Le. _ s-'411 �/A- 7IP lQ(62,3 CONTRACTOR PHONE: 20(0-(95 ( - 2' I'7 CONTRACTOR EMAIL: clear e,ne I e_rYtrroO Sea•COM CONTRACTOR LIC.#(REQUIRED): MeeR e4022(�� CITY OF EVERETT BUSINESS LIC.#(REQUIRED):03$ OO PRIMARY CONTACT: 0 OWNER TRACTOR 0 OTHER(Please Specify) O CONTACT NAME: p{ I CONTACT PHONE: 2V - S( -2� CJI K Jl r I,C�I !e l�U re CONTACT EMAIL:oh Q AL l @ m� -- -Ir(St.c()vv.1 AGREEMENT: The undersigned applicant agrees to co y with all provisions of the Everett Municipal Code Title City of Everett Official Use Only 14 Water and Sewer or such otherrules and regulations now existing or which may be established from time to FEE O time. The applicant further agrees.as a condition precedent to receiving service that the utilities division shall have �J D the right at any time,without notice,to shut off or turn on the water supply for repairs.construction.and ✓f✓ -� nonpayment of charges or for any other reasonable cause.I am the owner.ort am authorized by the owner of this property to perform the work .r which application is made.and f comply with the State Contractors Law 18.27 FERMI # and 2••200A WA U 3.14 -1 (0 0 erlAuthorized •g:1 Signaturi Date (Revised 10/12/2015) •