2431 VIRGINIA AVE 2017-01-24 - Laserfiche WebLink

. �� '�I�� I�� CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P) 425-257-8810 � FAX 425-257-8851 � (�) everetteps@everettwa.yov � www.everettwa.gov/permits PROJECT SITE IPIFORM/�TION PROJECT ADDRESS: �l/ � � �� 1 IF APPLICABLE: ❑ OUTSIDE CITY LIMI ❑ 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 �1PPLICATION INFORMATION SEWER(check all that apply) WATER(check all that apply) ❑ SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION ❑ S1DE 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 MULTIPI_E DOMESTIC WATER SER�JICES REG1UFST WATFR SERVICF TYP1=/S17F: (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 TNIS FORM. CONTACT INFORMATION OWNER NAME: TENANT NAME(If Commercial): OWNER MAILING ADDRESS: srReET CITY STATE ZIP OWNER PHONE: OWNER EMAIL: __. ._. _ --_.._ ., _._.. .. _ . ...._ __._. _._, ._.. .._ . .__......_ . ._ ... _. .._... .._... CONTRACTOR NAME: �• '� � ' � ;;� ,� / �tl � M CONTRACTOR ADDRESS: sTReer ''�' `f g ``�y ,� .�� `�✓ � ��.'� 7 �4 0�')�. CITY �i , ,�� STATE ;'� J�� ZIP �, � ,G� CONTRACTOR PHONE � ��j � ��'� ��j CONT ACTOR EMAIL �� `°L' ,��,��_]'� J��"'�y/� j��,�� L��°�'�s .��% '� CONTRACTOR LIC.#(REQUIRED): � p� '�, � �� '� � CITY OF EVE�ETT BUSINESS��LIC.#(REQUIRED): �'� � �� "' PRIMARY CONTACT: ❑ OWNER ❑ CONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: � �'� .-- �/�� 9 f �� CONTACT EMAIL � r � � � i r�'!�'�� ' ��6�'�- � �t '%��l '��L' �1'?� � � �(; Z�'��C� '1' r�i ' � ��L AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title � City of Everetf�� cial Use On/y 14 Water and Sewer or such otl�er rules and�egulations now existing or which may be established from trme to FEE � time. The applicant fu�ther agrees,as a condition precedent to receiving service that fhe utilities drvisron shall have �L� the right at any time,withouf notice,to shut off or furn on the water supp/y forreparrs, consfruction, and �'�� _/ nonpayment of charges or for any other reasonable cause.I am the owner,or I am authorized by the owner of this property to perform the v✓ork for which application is made,and,l comply with the Sfate Contractors Law 18.27 PERMIT# RCW nd 296.20QA WAC. '' , 1�1 ��,��'� � ��-��'� ��:�`� '�% �� '7� ! P �� '�� -�% I (�y Owner/Authorized Agent Signature Date (Revised 10/92/2015)