5132 27TH AVE W 2017-01-13 - Laserfiche WebLink

�.�✓_' r� (P) 425-257-8810 v�r�t�is�w�� u�iLi�v��i��ioN CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 FAX 425-257-8857 �(E) everetteps@everettwa.gov � www.everettwa.gov/permits PROJECT SITE INFORMATION ��/ PROJECT ADDRESS: �I Z%� cX �� IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDING AREA 5F ❑ LOT # BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-# OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? ❑ 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 ❑ 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 ❑ DOMESTIC: 3/4", 1", 2", OTHER: MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ �RRIGATION: 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: � .5'✓1''� � f TENANT NAME (If Commercial): OWNER MAILING ADDRESS: sTReer �j t�2 2-%r`' �� L-J C � CITY � -- -- L ��' . STATE �.(,J� ZIP OWNER PHONE: Z -%6 0�-/�� OWNER EMAIL: � CONTRACTOR NAME: C �l. S Y" f�� «��il r CONTRACTOR ADDRESS: sTReer �55t� /�� E'd1 �J'c��^>c� «V`2 CITY �E �n STATE �/IJL� ZIP ��/ G � CONTRACTOR PHONE: CONTRACTOR EMAIL: CONTRACTOR LIC. #(REQUIRED): CITY OF EVERETT BUSINESS LIC. #(REQUIRED): DVJ� �G� PRIMARY CONTACT: ❑ OWNER CONTRACTOR ❑ OTHER (Please Specify) CONTACT NAME: CONTACT PHONE: 2(i(�' ,331 - 72 �( S ��C�'� �Gtl�✓l �V'�,[ l ( CONTACT EMAIL: �;� J . �Z�PL � /�-ta� � / , CO'l�t-� HUf'CCCIVICIV l: I Ild Il!lUC/JI[JIICU d�Jflll(Jdll! d(�/CE:J W GUIn(JI}� wllN du �Jl V VIJ/U/w Ui uic cvcicu mwu��Na� �.uuc � u�c 14 Water and Sewer or such other rules and regulations now existing or which may be esta6lished from time to time. The applicant further agrees, as a condition precedent to receiving service that the uiilities division shall have the right at any fime, wifhout notice, to shut off or turn on the water supply for repairs, constniction, and nonpayment of charges or for any other reasonable cause. I am the owner, or I am authorized by the owne� of this property to perform th work for whrch applicatiop is made, and 1 comply with the State Contractors Law 18.27 RCW and 96.200 AC. � %� ' l iw �ic/G � / 2� C� Signature /Date �.ny v� �vcictt vurz,ia� vac vniy FEE ( �� ` rC� c PERMIT # � i ��I ' 0�? (Revised 1 D/12/2015)