1831 LOMBARD AVE 2016-09-13 - Laserfiche WebLink

WAFER 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.gov1permits -IO�Z_MATION - PROJECT SITE . PROJECT ADDRESS: VI/ 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 INFORMAT16N 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: ❑STALL 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", 111, 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: V. 2", OTHER: SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. CONTACT INFORMATION OWNER NAME: ' TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET i CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: VVV CONTRACTOR ADDRESS: STREET 11�l1�J�r/III V I CJ V r X ' CITY STATE ZIP U (i CONTRACTOR PHONE: 42-S- 8 -b t'2 S 1CONTRACTOR EMAIL: �l'V1 CONTRACTOR LIC.#(REQUIRED): 0 CITY OF EVERETT BUSINESS LIC.#(REQUIRED): PRIMARY CONTACT: ❑OWNER �MONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: 149L)co S M �— 2 C'T VK-0- _ 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 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 . the right at arwTtNel without notice,to shut off or turn on the water supply for repairs,construction,and nonpayme of ch s or for other reasonable cause.lam the owner, or l am authorized by the owner of this property t pe m work for w ch application is made,and I comply with the State Contractors Law 18.27 PERMIT# /// RCW an 29 .200 C. ^ � J� U � �O / „� /I1/15 Owner/Au ri ent Si Date (� (Revised 10/121201/5) w