812 GRAND AVE 2016-05-20 - Laserfiche WebLink

• OLT WATER / SEWER UTILITY APPLICATION 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 I www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: ''' iZ.C1;21 01/-\�j� Ll ✓L c- (Jz i\ IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ODULEX ❑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) SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION ❑ SIDE SEWER ALTERATION ❑ COMPLETE SERVICE 0 METER ONLY 1 ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: ❑ INSTALL BACKWATER VALVE(outside the building) ❑ SFR 0 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 0 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: _)CAI v1 LlGtV C—R TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET Gr2Ave6T _ CITY k-LJ•QVC.U STATE W - ZIP cip C OWNER PHONE: q2`,- 2s--2._-- C f7c7r OWNER EMAIL: CONTRACTOR NAME: C,S 0v,,,,,o`sA, CONTRACTOR ADDRESS: STREET �32 : ,- ZI 1\0 V._ �712Vi"ni J.. CITY STATE J ZIP r(ct2S Z CONTRACTOR PHONE: 3(..)O C-3(1'(S(c c7 CONTRACTOR EMAIL: ��j -'7I1/4..SYkA14 1,- iNJ< 'COA CONTRACTOR LIC.#(REQUIRED): C;ssp(p3S lTi(L-34 CITY OF EVERETT BUSINESS LIC.#(REQUIRED): (+ t IH PRIMARY CONTACT: 0 OWNER rCONTRACTOR ElOTHER(Please Specify) CO ACT NAME: CONTACT PHONE: ` (oci 1 �sc...(� y Z3 ---1(: ' � , /1/510h1450CONTACT EMAIL: Q._ vWvAa. 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 101( 1--- 0 the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and nonpayment of charges or for any other reasonable cause.I am the owner,or I am authorized by the owner of this pro,•,-• to perform the •k for which application is made,and I comply with the State Contractors Law 18.27 I ,�1/ �^JPERMIT I # W an%6.200 • ,.. /- &--" v� �6 l CO v ( - v O Owner ?orized Agent Signature Date (Revised 10/12/2015)