8210 BEVERLY BLVD 2017-11-28 - Laserfiche WebLink

WATER / SEWER UTILITY APPLICATION •• ► C-A CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P)425-257-8810 I FAX 425-257-8857 I (E) everetteps@everettwa.gov I www.everettwa.gov/permits PROJECTt-7,),---,41-1. SITE I NFORMATI ON PROJECT ADDRESS: zit) �jc�c*'l 6kve)• v- i4 qg ZA7 IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT# BUILDING TYPE: ,FR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? W-NO 0 YES, FROM TO UTILITY APPLICATION INFORMATION SEWER(check all that apply) WATER (check all that apply) yj SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION ❑ SIDE SEWER ALTERATION ❑ COMPLETE SERVICE 0 METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: ❑ INSTALL BACKWATER VALVE(outside the building) 0 SFR ❑ SIDE SEWER CAP-OFF 0 MULTI-FAMILY-#OF UNITS: ❑ SIDE SEWER RECONNECTION 0 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: ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑ FIRE: 1", 2", 4", 6", 8", OTHER: SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER 0 DOMESTIC/FIRE COMBO: 1", 2", OTHER: SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. /� rr CONTACT INFORMATION OWNER NAME: 1L_ (3;i�.l..;v� TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET Z-LO1,3e-✓cv/j l3 L ,) L : CITY VrAcc "`yII� STATE VIJA- ZIP f1lg ZD 3 OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: CONTRACTOR ADDRESS: STREET ..2-40 I, 5t.,3 ff. 6\-. 1 CITY STATE 'LAD A- ZIP `V CONTRACTOR PHONE: ZC, - `152-- 1111 CONTRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): SOS; 1 N P Z i L(O CITY OF EVERETT BUSINESS LIC.#(REQUIRED):O69 O 30 PRIMARY CONTACT: Cl OWNER MCONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: (zp( Lk4c -- 44`a ) iNk Aar✓'.5 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 maybe established from time to FEE time. The applicant further agrees, as a condition precedent to receiving service that the u''ies division shall have the right at any time,without notice,to shut•ffor turn on the water supply for repairs, nstr ction,and nonpayment of charges or for any other -95onable cae, I am the ow =,or I am-;thoriz d by the owner of this property to perform the work for whi plication.,mrep"and I ca ° he ate C. tractors w 18.27 PERMIT# RCW and 296.200A WAC. // 10/12/2015 Owner/A thorized Agen ignature Date (Revised )