2107 LOMBARD AVE 2016-09-14 - Laserfiche WebLink

WATER / SEWER UTILITY ILITY APPLICATII©N CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT,WA 98201 (P) 425-257-8810 FAX 425-257-8857 1 (E) everetteps@everettwa.gov www.everettwa.gov1permits RRp ECT SITE IN 09 PROJECT ADDRESS: (1/101 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 INFORM,ATION 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: l 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. FILL OUT REVERSE SIDE OF THIS FORM. CONTACT INFORMATION OWNER NAME: ' TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET CIN STATE Zip OWNER PHONE: OWNER EMAIL• CONTRACTOR NAME: V Imo^ VA CONTRACTOR ADDRESS: STREET I V ( `D CITY Ve V.- STATE �P �+ v CONTRACTOR PHONE: Z g -b l 2 CONTRACTOR EMAIL: IV V1,7 CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED): U IS PRIMARY CONTACT.'M❑'OWNER xONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: n CONTACT PHONE: 148 6�— 6 l 2-3 I v� CJT— CONTACT EMAIL: AGR T.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 maybe established from time to FEE l] time_The applicant further agrees, as a condition precedent to receiving service that the utilities division shall have the right at arxTINe,without notice,to shut off or turn on the water supply for repairs,construction,and U nonpayme ofch s or for otherreasonable cause.1 am the owner,orl am authorized by the owner ofthis properly i pert m work for w 'ch application is made,and!comply with the State Contractors Law 98.27 =6TOD RCWan 29 .200 C. .� �/� I DD� Owner/Au ri ent Si Date (�' (Revised 90/1212095)