1606 LOMBARD AVE 2016-09-13 - Laserfiche WebLink

WATER / SEWER UTILITY APPLICATION CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT,WA 98201 (P) 425-257-8810 j FAX 425-257-8857 j (E) everetteps@everettwa.gov www.everettwa.gov/permits PROJECT SIZE 114F RM -1®IV PROJECT ADDRESS: IF APPLICABLE: ❑OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY4 OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? ❑NO ❑YES, FROM TO UTILITY APPLICAT-10 INFOR A'i'IOIN _. SEWER(check all that apply) WATER(check all that apply) ❑ SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION ❑ SIDE SEWER ALTERATION ❑ COMPLETE SERVICE El.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 I SIZE: (circle desired size) ElI AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR ElDOMESTIC: 3/4', 1", 2", OTHER: NIY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ IRRIGATION: 3/411, 1", 2", OTHER: ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑ FIRE: 7", 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: ' TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET CITY STATE 71P OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: f fir- ��, � ✓� �� CONTRACTOR ADDRESS: STREET j/C� VVfI� U ( 7 CITY �/�V�`� STATE E ZIP (� CONTRACTOR PHONE: G 2-- S -b l 2 (CONTRACTOR EMAIL: yff'PCMjb11 CONTRACTOR LIC.#(REQUIRED) 1q CITY OF EVERETT BUSINESS LIC. (REQUIRED): US_ PRIMARY CONTACT:^ '❑'OWNER O ITRAC_TC R ❑ OTHER(Please Specify) CONTACT NAME: p CONTACT PHONE: LIZ 5- 148 3 CONTACT EMAIL: AGREEMENT. The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title City of Everett Official Use Only 14 Waterand Sewerorsuch otherrules and regulations now existing or which maybe established from time to FEE Q time- The applicant further agrees, as a condition precedent to receiving service that the utilities division shall have -� the righf ata r e,without notice,to shut off or tum on the water supply for repairs,construction,and nonpayme of chnasonable cause.t am the owner,or am authorized by the owner of this properly t pert lication is made,and I comply with the State Contractors Law 18.27 PERMIT# RCW an 29 .200UOwner/Au ri Date (� (Revised 10/12/2015) J