1612 MAPLE ST 2018-01-04 - Laserfiche WebLink

_ ��'��'�� 6 ��I� '� ��B�� CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P) 425-257-8810 � FAX 425-257-8857 � (E) everetteps@everettuva.gov � www.everetfiwa.gov/permits ��D ��' ��`�� BP��'@�� PROJECT,ADDRESS: � IF APPLIC,�,BLC: ❑ OUTSIDE CITY LIMIT ❑ BUILDING AREA SF ❑ LOT# BUILDING TYPE: ❑SFR-0ETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHAIVGE OF USE? NO ❑YES, FROM TO U�B�i`f�lr AP��C��°I�� t@��6��1i�`1�8�� SEWEF2 (check all that apply) Vi/ATER (check all that apply) I�SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION ❑ SIDE SEWER ALTERATION ❑ COMPLETE SERVICE ❑ METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: L� 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 SEFZVICE 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. FILL OUT REVERSE SIDE OF THIS FORM. COWTACT IRI�ORIVI�A��Of� OWIVER NAME: � n � � TEPIANT NAIVIE(If Commercial): OWNER MAILING ADDRESS: srREET CITY STATE � ZIP � I OVIdPVER PHONE: OWNER EfVIR,IL: CONTRAC70R f�,4ME: CONTRACTOR ADDRESS: sTREET ,� ��7y STATE � o ZIP CONTRACTOR PHOi�E: ' '� CO 7RACTOP.EMAfL_ � � 1 ' m p� CONTRACTOR LIC.#(REC�UIRED): CITY OF EVERETT BUSI�! LIC.#(REQUIRED): O PRIIViARY CONTACT: ❑OWNER ❑ CONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: o COI�TACT PHO�IE: � �� �� ,�`� ��,"�i I� COfVTACT ENIAIL: � � � � � , AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal ode Tifle City of Ever t Otfrcial Use Only 14 Water and Sewer or such other rules and re�ulations now exisfing or which may be establisl�ed f�om time to FEE time. The applicant fiuther ayrees, s conc�i' n precedenf to�eceiving service that the utilitics division shall have /� the righf af any ' e, wi t notic , to shut off o turn on the water supply for repairs,construction, and �� nonpayment f ch r s or or an other reasona le cause.l am the owner,or I am authorized by the owner of this �( � properfy to p forn he wo r hich applicatio is made,and I comply with the State Confracfors Law 18.?_7 PERMIT# RCW and 29 200 Wl1C � " p, � � �, � � �_ �� =�.ti-�� 0 wner/Authoriz gent Sig ature Date (f�evised 10/12/2015)