7826 E CASINO RD 2018-01-03 - Laserfiche WebLink

�V.�i�Q�'�� L�� M`��`��l /�pC�I�O�C�"l�8�6� 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 PFZ�J�C�' SI`�� I��OR�fi�u'I�id PROJECTADDRESS: �(j ' � R.�. IF APPLfCABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILQING AREA SF ❑ LOT# BUILDING TYPE: ❑SFR-DETACHED SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY�#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? ❑NO ❑YES, FROM TO u��.a°rv ��'c,��'oor� ar��o�n��-io� SEWER(check all that apply) WATER(check all that apply) SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION ❑ SIDE SEWERALTERATION ❑ COMPLETE SERVICE ❑ METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: ❑ INSTALL BACKWATER VALVE outside fhe 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. ❑ IRR(GATION: 3/4", 1", 2", OTHER: ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑ F{RE: 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: i .Q, �Cl� TENANT NAME(If Commercial): OWNER MAILING ADDRESS: srReer 78��O � . C-� � n �� CITY �j Q�C STATE G�- ZIP �c.O� OWNER PHONE: OWNER EMAIL: .,,,.�.. _�,�_:.._v ....�._,,,_..�.,;.., ..... _� .. ..... . ......�,_ ...w,, �.,.. ,. CONTRACTOR NAME: �y IQ,Y I� e- Q �'� ��'� CONTRACTORADDRESS: sTREer S/�i �U`� a . 'W �TG lO ( CITY P U t' � � STATE � ZIP f�O� CONTRACTOR PHONE: ' Z - S� CONTRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): Re. �� O CITY OF EVERETT BUSINESS LIC.#(REQUIRED): J��5 PRIMARY CONTACT: ❑OWNER' CONTRACTOR ❑ OTHER(Please Specify) CONTAC7 NAME: "ry 1.Q�'� }�i,2s51,��( CONTACT PHOIVE: 2Ojp Z,OO �aZ� ! CO�ITACT EMAIL: AGREEMENT.'The undersigned app/icanf agrees to comp/y v✓ifh al/provisions of the Evereff Municipa/Code Title City of Everett Official Use On/y 14 Water and Sewer or such ofher rules and regulations now existing or which may be established from time to �EE � _ time.The applicanf furfher agrees, as a condition precedenf to receiving service that the utilifies division shall have � the right at any time,withouf notice,to shut off or fum on the water supply forrepairs,construction,and nonpayment of charges or for any other reasonable cause.I am fhe owner,or!am autftorized by the owner of this property to perform the work for which application is made,and I comply with the Sfate Contractors Law 18.2T P�RMIT# RCW nd 296.200A WAC. � \ �� r /�'� I��/~'�`� D te � ' � (Revised 90/12/2095) v O erlAuthorized Agenf Siynafure