1827 72ND PL SE 2017-01-13 - Laserfiche WebLink

ViIATER / SEWER UTILITY APPLICATION - 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/permits PROJECT SITE INFORMATION PROJECT ADDRESS: ��j�� 7�� L S L IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT# BUILDING TYPE: SFR- ETACHED ❑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) ❑ SID EWER 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: ��F� L.+I'�''-.4'�[-L TENANT NAME(If Commercial): S��c OWNER MAILING ADDRESS: srREET ��27 7?'A �/ S� Y_ STATE VC.<L� ZIP �U�� c�,v '�rc'nE7� OWNER PHONE: `f�> 3�y 3 y 7 '7 OWNER EMAIL: ��/"��i:Mn�n.;_,C= hv��,�; 1•�c.�, CONTRACTOR NAME: ; ��r� G,A.24C"�i 5 ��'�= CONTRACTOR ADDRESS: s-rReET �'Y��l Lc��B ,��+� ��ti�T � CITY /��ZLr� STATE (�,Ji� ZIP 4�L.''�=� CONTRACTOR PHONE: �I�'S ��i `c3 ��5 Z. CONTRACTOR EMAIL: ��r'.S�r � �r`'d'-'� ` �m's CONTRACTOR LIC.#(REQUIRED): ��FG-� ��t�''��'n-'� CITY OF EVERETT BUSINESS LIC.#(REQUIRED): PRIMARY CONTACT: ❑OWNER • CONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: Lf Z j ��, �� 7 s � �1� �'��S��'� CONTACT EMAIL: � q� c-�,r c v � ��Mc.�; �. cC�-t AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Evereft Municipal Code Title City of Eve�ett Official Use On/y 14 Water and Sewer or such other rules and regulations now existing or whrch may be esfablished from time to FEE time. The applicant furfher agrees, as a condition precedent to receiving service that the utilities division shall have �� Q� the�ight at any time, without notice, to shut off or turn on the water supply for�epairs,construction, and nonpayment of charges o�for any other reasonable cause. I am the owner, or I am authorized by the owner of this property to perfo�m the work for which application is made,and I comply with the State Contractors Law 18.27 PERMIT# RCW and 296.200A I�C. � ��.�� /�� U a � o C - D �" 7wner/Authorized Agent Signature Date (Revised 10/12/2015)