1818 LOMBARD AVE 2016-09-13 - Laserfiche WebLink

WATER I SEWER UTILITY APPLICATION 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 PR®JEC`T Sil'E IN>=OpMATION PROJECT ADDRESS: 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 U-tiL1TY,p1PPLICATlOt4 lNFORMA*tiON' SEWER(check all that apply) WATER(check all that apply) ❑ SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION ❑ SIDE SEWER ALTERATION El COMPLETE SERVICE 0-METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: 0 INSTALL BACKWATER VALVEoutside 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) ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR ❑ DOMESTIC: 314', 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: V, 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 ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: CONTRACTOR ADDRESS: STREET (Sd I V t (-A-,Vd A AA CITY -Z VeV`�`�� STATE ZIP (i v CONTRACTOR PHONE: 2 8 'd` Z /CONTRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC. (REQUIRED): PRIMARY CONTACT:w❑OWNER CONTRACTOR ❑OTHER(Please Specify) CONTACT NAME: LA CONTACT PHONE: �ZS'- 14 8 67— 0 l 2-3 C'- KOLI - CONTACT EMAIL; AGREEMENT.The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title City of Evereft Official Use Only 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to FEE +� DO time- The applicant further agrees, as a condition precedent to receiving service that the utilities division shall have ff '�© the right at a e,without notice,to shut oor turn on the watersupply for repairs,construction,and `yY � nonpayme of ch s orfor otherreasonable cause.I am the owner,orl am authorized bythe ownerofthis property t pert m work for w 'ch application is made,and I comply with the State Contractors Law 18.27 =9 © RCW an 29 .200 C. ,�J� k Owner/Au ri ent Si Date (Revised1011212015)