1511 MCDOUGALL AVE 2016-08-24 - Laserfiche WebLink

��1�� SEW�� .��Y L�� CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P) 425-257-8810 � FAX 425-257-8857 �(E) everetteps@everettwa.gov � www.everettwa.gov/permits PROJECT SITE INFORMATION � PROJECT ADDRESS: � ` �� OUG �, ; � � � ��.�. �1'� il w � � ��: "` IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDING ARE SF ❑ LOT # BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX MULTI-FAMILY-# OF UNITS:� ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? � N� ❑ YES, FROM TO UTILITY APPLICATION INFORMATION SEWER (check all that apply) WATER (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 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 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. F/LL OUT REVERSE SIDE OF THIS FORM. CONTACT INFORMATION WNER NAME: �(^'�� ,fi'��r�r�� v�'', � TENANT NAME (If Commercial): OWNER MAILING ADDRESS: sTREET � Y� C ��` , �� � �. L CITY L'� �" I� � � STATE � � ZIP �� OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: �; '� � �Q, r CONTRACTOR ADDRESS: sTREEr I � E�i ^ CITY - STATE Vv ZIP l �. CONTRACTOR PHONE: CONTRACTOR EMAIL: CONTRACTOR LIC. #(REQUIRED): CITY OF EVERETT BUSINESS LIC. #(REQUIRED): PRIMARY CONTACT: ❑ OWNER ❑ CONTRACTOR ❑ OTHER (Please Specify) CONTACT NAME: CONTACT PHONE: CONTACT EMAIL: AGREEMENT: The undersigned applicant agrees fo comply with all provisions of the Everett Municipal Code Title 14 Water and Sewer or such other �ules and regulations now existing or which may be established from fime to time. The applicant further agrees, as a condition precedent fo receiving service that the utilities division shall have fhe right at any fime, without notice, fo shut off or turn on the water supply for repairs, construction, and nonpayment of charges or for any other reasonab/e cause. 1 am the owner, or I am aufhorized by the owner of fhis property to perform fhe work for which application is made, and l comply with the State Contractors Law 18.27 RCV�nd-�9fyt200A WAC. � �— - — '�� ---'�� _� `-� �� Owner/Authorized Agent Signature Date City of Everett Otficia/ Use Only FEE � �� PERMIT # � �l�D �bl� (Revised 10/12/2015)