1015 LOMBARD AVE 2016-08-12 - Laserfiche WebLink

(P) 425-257-8810 WATER / SEWER UTILITY APPLICATION CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 FAX 425-257-8857 �(E) everetteps@everettwa.gov � www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: [ � � � - r � I IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT # BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-# OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? � NO ❑ YES, FROM TO UTILITY APPLICATION INFORMATION SEWER (check all that apply) �-(check all that apply) � SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION ❑ SIDE SEWER ALTERATION ❑ COMPLETE SERVICE ❑ 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 T 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 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: �; � '�"1 � T NANT NAME (If Commercial): OWNER MAILING ADDRESS: sTReer i(� �� L YYL 'Y�' CITY STATE �� ZIP l OWNER PHONE: �Z�- ��ZI ��Q OWNER EMAIL jrlS. %��lb� S a��% C,�Gl� -.-A CONTRACTOR NAME: ��' (,1 '"��/ ,l � � �jd�� CONTRACTOR ADDRESS: s EET � � �'O %� ` f � /� � � CITY � t � STATE /f �. ZIP f1 � 1� CONTRACTOR PHONE: 3 - �",�j " �S � CONTRACTOR EMAIL: f'�L�, _ ' �' �/�� , i� s^(� � "� r (, 'I'�'4 CONTRACTOR LIC. #(REQUIRED): � �� .I.� � U 1� E'-- CITY OF EVERETT BUSINESS LIC. #(REQUIRED): Oo�S 3 PRIMARY CONTACT: �OWNER ❑ CONTRACTOR ❑ OTHER (Please Specify) CONTACT NAME: CONTACT PHONE: ri , �y�"��`+ " � � ' �� �� , CONTACT EMAIL: .� �, , �. C J� AGREEMENT: The undersigned applicant agrees to comply with a// provisions of the Everett Municipal C�de itle City of Everett O icial se On/y 14 Water and Sewer or such other rules and regu/ations now existing or which may be established from time to 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 o(f or turn on the water supp/y for repairs, construction, and nonpayment of charges or for any other reasonable cause. I am the owner, or I am authorized by the owner of this property to perform the work for which application is made, and 1 comply with the State Contractors Law 18.27 RCW and 296.200A ��.� C�t � ��3- � � Owner/Authorized Agent Signature Date FEE � �� PERMIT # U �� - (Revised 10/12/2015)