1326 48TH ST SW 2017-01-13 - Laserfiche WebLink

(P) 425-257-8810 1SVATER / SEIIVER IJiILIiY AP�LIC�4TION 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: f,j C� `� Sj� 5�.� 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? �1 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 1 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. ❑ 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, CONTACT INFORMATION OWNER NAME: � r,.,,� /�/t� TENANT NAME (If Commercial): OWNER MAILING ADDRESS: srReEr ��Ty STATE ZIP OWNER PHONE: �,�-S ��S " 3%�'�' OWNER EMAIL: CONTRACTOR NAME: ,L� -��i�.I, CONTRACTOR ADDRESS; sTReeT �' / � � f CITY �,� STATE � � ZIP �'I ��(y CONTRACTOR PHONE: b�=�,j � S.Z 7(� CONTRACTOR EMAIL: CONTRACTOR LIC. #(REQUIRED): OK.� c�TL �(;��(z CITY OF EVERETT BUSINESS LIC. #(REQUIRED): USj � j PRIMARY CONTACT: ❑ OWNER � CONTRACTOR ❑ OTHER (Please Specify) CONTACT NAME: CONTACT PHONE: ��/_Z�7 � j�? �{, [-`.n / K C7if !/ CONTACT EMAIL: AGREEMENT: The unde�signed applicant agrees to comply with all provisions of the Everett Municipal Code Title 14 Water and Sewer or such other rules and regulations now exisfing or wliich may be established from time to time. The applicant further agrees, as a condition precedent to receiving service that the utilities division shall have the right at any time, without notice, to shuf off or turn on the water supply for repairs, constn�ction, and nonpayment of charge,s or for any other reasonable cause. I am the owner, or I am authorized by the owner of this properfy to perform ti�e work for which application is made, and 1 comply with the State Contractors Law 18.27 RCW anrJ�296.200A WAC. , � .�� !/ Y //� Owner/Authorized Agent Signature Date City of Eve�ett Official Use Only FEE � �� .��-'�� PERMIT # U 1 G�1 �� `" ()� �.�J (Revised 10/12/2015)