1812 LOMBARD AVE 2016-09-13 - Laserfiche WebLink

WATER. / SEWER UTILITY APPLICATION CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P) 425-287-8810 FAX 425-257-8857 1 (E) everetteps@everettwa.gov www.everettwa.gov/permits PROJEC'� S1'rE II�LFOOZMATIOM PROJECT ADDRESS: IF APPLICABLE: ElOUTSIDE 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 IMFORMATIO SEWER (check_ _. ._ . . - -. .. _ . ..._ _ .._.. ( k 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: E31'NSTALL 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: 3141, 1", 2", OTHER: MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ IRRIGATION: 314", 1", 2", OTHER: ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑ FIRE: 11, 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 ZP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: CONTRACTOR ADDRESS: STREET j/ r/vfll c',/� Xr) r� CITY I �/�VN"' STATE 71P U v CONTRACTOR PHONE: 2 S -612 SICONTRACTOR EMAIL: l�✓ �1'� Ll CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC. (REQUIRED): bS_ PRIMARY CONTACT: '❑OWNER #ONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: !I Z�� 14 g ?— CJ 2 V I C'T f��— _ CONTACT EMAIL: l AGREEMENT.•The undersigned applicant nt agreees to comply with all provisions of the Everett Municipal Code Title City of Everett Official Use Only 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to FEE time- The applicant further agrees, as a condition precedent to receiving service that the utilities division shall have theright at a e,without notice,to shut off or tum on the watersupply for repairs,construction,and v nonpayme of ch s or for other reasonable cause.I am the owner,or I am authorized by the owner of this property t pert m work for wL'chapplication is made,and I comply with the State Contractors Law 16.27 PERMIT# RCW an 29 .200 C. , J- � r (r �1 v / Owner/Au ri ent Si Date (Revised 10/9212015)