2601 LOMBARD AVE 2017-01-13 - Laserfiche WebLink

; j ,�. �t - - �, - , , � �. ,� � � � � �i CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P) 425-257-8810 � FAX 425-257-8857 �(E) everetteps@everettwa.gov � www.everettwa.gov/j�ermits PROJECT SITE IPIFORMATION PROJECT ADDRESS: � t,' � n r 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 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 51DE SEWER INSTALLATION SERVICE / METER USE: � INSTALL BACKWATER VALVE (outside the building) ❑ SFR ❑ SIDE SEWER CAP-0FF ❑ MULTI-FAMILY -# OF UNITS: ❑ SIDE SEWER RECONNECTION ❑ COMMERCIAL MULTIPLF_ DO�AESTIC INATER SERI/ICF_S REC�UEST UVATER SERVICE TYPF / S17F� (cirde 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. 14 Water and Sewer or such ofher rules and regulations now existing or wl�ich may be esfablished frorn time to time. The applicanf further agrees, as a condition precedent to �eceiving service that the utilitres division shall have ihe right at any time, wifhout notice, fo shut off or turn on the wafer supply for repairs, construction, and nonpayment of charges or for any other reasonable cause. I am fhe owner, or I am authorized by ihe owner of this property to perform the work for which application is made, ant�l comply with fhe State Contractors Law 18.27 RCW �nd 296.20�A WAC. ' � 9 � s:� .�� .-�-�� -�r��.�� ; I � i�,� r � � Owner/Authorized Agent Signature FEE i, �j�} `�?� p, � PERMIT # lJ i �Y C��- ��i (Revised 10/12/2095)