2623 CLEVELAND AVE 2016-05-17 - Laserfiche WebLink

WATER / SEWER UTILITY APPLICATION CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P)425-257-8810 I FAX 425-257-8857 I (E)everetteps@everettwa.gov I www.everettwa.gov/permits . .amtioaa ix i 1o* xire 21TiJs „ ESN42 PROJECT ADDRESS: ( ek eld/?d i9 tJ IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ,❑,,SFR-DETACHED IRS{R-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL 0 INDUSTRIAL CHANGE OF USE? "l�� 0 YES, FROM TO W ,k, = TL1TYAPP:,LCATION IN MAI'10 ` � � .-. AI SEWER(check all that apply) WATER(check all that apply) SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION ❑SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY ❑NEW SIDE SEWER INSTALLATION SERVICE/METER USE: ❑INSTALL BACKWATER VALVE(outside the building) 0 SFR ❑SIDE SEWER CAP-OFF 0 MULTI-FAMILY-#OF UNITS: ❑SIDE SEWER RECONNECTION 0 COMMERCIAL MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE:(circle desired size) ❑I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR 0 DOMESTIC: 3/4", 1", 2", OTHER: MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. 0 IRRIGATION: 3/4", 1", 2", OTHER: ❑I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER 0 FIRE: 1", 2", 4", 6", 8", OTHER: SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER 0 DOMESTIC/FIRE COMBO: 1", 2", OTHER: SINGLE OWNERSHIP.FILL OUT REVERSE SIDE OF THIS FORM. W� _ -�_mx?: Al ! r COxTWT...aI�CF4RMa+E�#1:0KIZYyZMYIi c < � � OWNER NAME: TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: A-+-.6euve I ecY\Y1Qlocji e� CONTRACTOR ADDRESS: STREET Afton C is n CITY (l4O r, STATE M/44 ZIP 9,,,55-5t CONTRACTOR PHONE: % 2-13 (45(o CONTRACTOR EMAIL:l`4 es, (p(-- h l er7y/) CONTRACTOR LIC.#(REQUIRED): (�I-Q� �d�- CITY OF EVERETT BUSINESS LIC.#(REQUIRED): (- 11 PRIMARY CONTACT: 0 OWNER pfCONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: c:vyytc:z. /041 ca}-6 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 D .4 )the right at anytime,without notice,to shut off or tum on the water supply for repairs,construction,and nonpayment• charges or for any other reasonable cause.I am the owner,or I am authorized by the owner of this t of property to'- orm the work for which application is made,and I comply with the State ntractors Law 18.27 PERMIT# RCWand••6.200A WAC. f • U fto2- c16" Owner/Au 1 'zed Agent Signature Da e (Revised 10/12/2015)