1824 HIGHLAND AVE 2018-01-04 - Laserfiche WebLink

1lVA`��R / ��W�� Tll I`�l� ��B��IOi� 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 PROJfCT SI'i"E INFARMIo►TION PROJECT ADDRESS: J�j Z' c, cJ (�-Q� IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ 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 APPLICATION INFORMATION SEWER(check all that apply) WATER(check ali 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: ❑ 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. F1LL OUT REVERSE SIDE OF THIS FORM. CONTACT INFORMATION OWNER NAME: 5 �v1< S �c-, TENANT NAME(If Commercial): OWNER MAILING ADDRESS: srREET CITY STATE Z�P OWNER PHONE: OWNER EMAIL: �._. ._ _..._�� ._:....., .� .... -- _..., . CONTRACTOR NAME: C�'I�c� �Z ' Tz=,i CONTRACTOR ADDRESS: srReET (��S S �(�.,C � T I CITY (,,� �i C. STATE C ZIP �/3�,_,) CONTRACTOR PHONE: �� 37C� '�� Z -7 CONTRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): �O C CITY OF EVERETT BUSINESS LIC.#(REQUIRED) � 7 7 Z`1 �.._. ��,.�_... __�.. ....... . ......_ . � PRIMARY CONTACT: ❑OWNER ❑ CONTRACTOR ❑OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: �.�ZS — � '�(, --C�� 7 1{``�� CONTACT EMAIL: AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipa!Code Title City of Everetf Otficial Use Only 94 VUater and Sewer o�such other rules and regulations now exisfing or which may be established from fime to FEE time. The applicant further agrees, as a condition precedent to receiving service that fhe utilities division shall have the righf at any time,withouf notice,to shut off or turn on the water supply for repairs,construction,and �i ` nonpaymenf of charges or for any other reasonab/e cause.1 am the owner,or 1 am aufhorized by the owner of fhis prope�ty to perform the work for which applicafion is made,and I comply with the Sfa e Contracfors Law 18.27 PERMIT# RCW and 296200A - / l � �� 1 O ^ �� _�— � / OwnerlA _gent Signafure Dat (Revised 10/12/2015J