1016 35TH ST 2017-10-26 - Laserfiche WebLink

W R / SEWER UTILITY ARPLICATION CITY OF EVERETT PERMIT SER CES 3200 CEDAR STREET, EVERETT, WA 98201 (P)425-257-8810 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: It IF APPLICABLE: ❑OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT# BUILDING TYPE: ,2tFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? )2'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 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. ❑ IRRIGATION: 3/4", 1", 2", OTHER: 111 AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑ FIRE: V, 2", 4", 6", 8", OTHER: SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER ❑ DOMESTIC/FIRE COMBO: V, 2", OTHER: SINGLE OWNERSHIP.FILL OUT REVERSE SIDE OF THIS FORM. CONTACT INFORMATION OWNER NAME: Coraw , 16 3 c TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET �g Safi CITYSTATE ZIP OWNER PHONE: 3� / OWNER EMAIL: CONTRACTOR NAME: yyt ST CONTRACTOR ADDRESS: STREET CITY STATE �` ZIP g_G4D6 CONTRACTOR PHONE: 9 'Z� (p CONTRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED)• C j 5 CITY OF EVERETT BUSINESS LIC.#(REQUIRED PRIMARY CONTACT: ❑OWNER ,CONTRACTOR ❑OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: Lr CONTACT EMAIL: P ouu It I I AGREEMENT. Thetr rsigned appl ant agre o comply with all provisions of the Everett Municipal Code Title City of Everett Official Use Only 14 Water and Seweuch other rul and re .' ions now existing or which may be established from time to FEE time. The applicant agrees,as conditio ecedent to receiving service that the utilities division shall have the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and v 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 work for which application is made,and I comply with the State Contractors Law 18.27 PERMIT# RCW and 296.200A WAC. Owner/Authorized ent Signature Date (Revised 10/1212015) 1