1522 126TH ST SE 2017-03-13 - Laserfiche WebLink

41577 W. ER / SEWER UTILITY t= PLICATION CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P) 425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov 1 www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: 75.2_,.-Z tig- 9/�,•2� IF APPLICABLE: ❑ OUTSIDE CITY LIMITS El BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED OSFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? ❑ NO El YES, FROM TO UTILITY APPLICATION INFORMATION SEWER(check all that apply) WATER(check all that apply) ❑ SIDE SEWER REPAIR S1 7a,5 ❑ NEW WATER SERVICE INSTALLATION ❑ SIDE SEWER ALTERATION caw� / ❑ COMPLETE SERVICE 0 METER ONLY X NEW SIDE SEWER INSTALLATION CrWeil SERVICE/METER USE: ❑ INSTALL BACKWATER VALVE(outside the building) 0 SFR ❑ SIDE SEWER CAP-OFF 0 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 0 DOMESTIC: 3/4", 1", 2", OTHER: MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. 0 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 El DOMESTIC/FIRE COMBO: 1", 2", OTHER: SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. `/ CONTACT INFORMATION OWNER NAME:ti /,� ,I,1-`/�/ie 4' TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET/5,2,2 /.2(2V1j S T- - CITY C�j/ .62� STATE /�j t ZIP / '( / OWNER PHONE: t/ _"% j OL' OWNER EMAIL:PC1! g�6j 0, RA,,ne' ie---/ CONTRACTOR NAME: /7L4"e-57 /.1 7/9L(7zCI /// CONTRACTOR ADDRESS: STREET CITY STATE ZIP CONTRACTOR PHONE: SLS-259 CONTRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED): PRIMARY CONTACT: ❑ OWNER El CONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: CONTACT EMAIL: AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title City of Everett Official Use Only 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to time. The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have FEE Q`DV OQ the right at any time,without notice, to shut off or turn on the water supply for repairs,construction,and nonpayment of charges or for any other reasonable cau I am the owner,or lam authorized by the owner of this prope , •perform the wo for whic ,i :tics ,. ..-,and I c• ply with the State Contractors Law 18.27 PERMIT# RCW..d.aiirAw. W' 401.111.14*., ,Cf// U 1(0 Owner/Authorized Agent Signature Date (Revised 10/12/2015)