2509 LOMBARD AVE 2017-01-13 - Laserfiche WebLink

(P) 425-257-8810 �,. - :, � _ _ '� - � %` '�° ' �' � � "� � CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 F/aX 425-257-8857 �(E) everetteps@everettwa.gov � www.everettwa.gov/permits PROJEC7' SITE IPIFORMATION PROJECT ADDRESS: � �)C � � �' " � 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? ❑ NO ❑ YES, FROM TO UTILITY APPLICATION INFORMATIOId 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 MULTIPL _F_ DOAAESTIC WATFR SER�IICF_S REQUEST �NATER SERVICF TYPF / SIZF_: (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 14 Water and Sewer o� such oiher rules and regulaiions now exisfing or which may be esfablished from time fo iime. The applicant further agrees, as a condition precedeni to receiving service fhat the utilities division shall have the right at any fime, withouf notice, to shut off or tum on the water supply for repairs, consfruction, and nonpayment of charges or for any otl�er reasonable cause. ! am the owner, or I am autho�ized by the owner of this property to perform the work for which application is made, anr(1 comply with the State Contracfors Law 18.27 RCW nd 296.20 A WAC. '' � ��- ,,, !� i ;'�� , Ai `� �' f�� / L� � � 4�; ��'1 �``�'r � � �) � �,� � {.t% Owner/Authorized Agent Signature F�E ��, � �� PERMIT # � � l� C��S�C�, � (Revised 10/12/2095)