2117 LOMBARD AVE 2016-09-20 - Laserfiche WebLink

WATE OR I 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 J www.everettwa.gov/permits PROJEC`1'SITE INFORMATION PROJECT ADDRESS: l Q,Ir 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 UT11LITY;APOLICATION LNFORMATION 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: Q 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) ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR ❑ DOMESTIC: 3/4", 1", 2", OTHER: MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ IRRIGATION: 3/4", 911, 2", OTHER: ❑ 1 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 OUTREVERSE SIDE OF THIS FORM. PONTACT„INFORMATION OWNER NAME: ' TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET CITY STATE ZJP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: ?rte / CONTRACTOR ADDRESS: STREET C� �I U (1,Va CITY VTC..V�� STATE ZIP Z/TD CONTRACTOR PHONE: 2- 8 �— )l 2 /C,OpNTRACTOR EMAIL: 1 v�6r V-1 CONTRACTOR LIC.#(REQUIRED): 1-'(JL�V/ ��/ f � CITY OF EVERETT BUSINESS LIC- REQUIRED 0�5 PRIMARY CONTACT:JY'❑OWNER TrvONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: 14 8 ?_ O l Z-3 ("U M C.T V-a' _ 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 17::: Q time_ The applicant further agrees, as a condition precedent to receiving service that the utilities division shall have O� the right ata r e,without notice,to shut off or turn on the water supply for repairs,construction,and nonpayme of ch s or for other reasonable cause.I am the owner,or I am authorized by the owner of this property f pert 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 © ' h OwnerlAu ri ent Si Date (1 (Revised 10/1212015) V