4959 ELM ST 2016-05-19 - Laserfiche WebLink

• WATER / SEWER UTILITY APPLICATION - . OLT CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P) 425-257-8810 I FAX 425-257-8857 1 (E) everetteps@everettwa.gov 1 www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: Li 1'5'1 'Lit-4A I • ..,V(. -+"f L)IA 61.75 J-5 IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT# BUILDING TYPE: ❑SFR-DETACHED DSFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? 0 NO ❑YES, FROM TO UTILITY APPLICATION INFORMATION SEWER (check all that apply) WATER (check all that apply) 1" SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION ❑ SIDE SEWER ALTERATION ❑ COMPLETE SERVICE 0 METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: ' ❑ 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 0 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. t�3 � CONTACT INFORMATION I\ OWNER NAME: ME E •-)1 (IOr'J TENANT NAME(If Commercial): -- OWNER MAILING ADDRESS: STREET `71999 L t '_ . �j ri CITY G \ a_c'e� /TT STATE L-j A zip U 'd 0 OWNER PHONE: 1S- 29q, 0115 OWNER EMAIL: R=VL1 peg 60 6) I1'0T10r 1,,(OuI. CONTRACTOR NAME: \5L,`t \- -l/G'\6.0 CONTRACTOR ADDRESS: STREET 51/'3' STOiN r_11-1-1--eft--- (,vA�% A) p / CITY <� ( STATE i1 ZIP CI ,')) 03 . CONTRACTOR PHONE: ' 41 -(0 .5-DlI7EO CONTRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): (7E ST PGL 915e---b- CITY OF EVERETT BUSINESS LIC.#(REQUIRED):030''/g5 PRIMARY CONTACT: ❑ OWNER .0 CONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: "R06 - °I 30 — U 7 AO. MIk_d_ g,/ I[; CONTACT EMAIL: Ii.ZIG:.. , k @ 6Es'rPL-VLv116 C7,(vci ' AGREEMENT.:The undersigned applicant agrees to comply with al 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 time. The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have -3V 4 the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and nonpayment of charge or for any other reasonable cause.I am the owner,or l ams authorized by the owner of this prope o p orm phe ork for which application is made,and 1 comply with the State Contractors Law 18.27 PERMIT# RCW a• \ 200L W C. H24. -'2'� 1 (&61 - ^�S U li /li(y/) Owner/Authorized Agent Signature Date (Revised 10/12/2015) %z