2502 PINE ST 2018-01-04 - Laserfiche WebLink

- . • � �� 0 �� Q��p�0��8�� CITY OF EVERETT PER�IT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P) 425-257-8810 � FAX 425-257-8857 � (E) everetteps@everettwa.gov � www.everetfiwa.gov/permifis ��0��`� �1�('� �t��e�`�8��1 PROJECT ADDRESS: [ � � IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT# BUILDIi�G TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? NO ❑ YES, FROM TO IJTILI'Tlf' �lP�&�ICA`�°IOE� If��O��➢ SEWER (check ail that apply) 1lV,4TER(check all that apply) �SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION ❑ SIDE SEINER ALTERATION ❑ COMPLETE SERVICE ❑ METER ONLY ❑ NEW SIDE SEWER IfVSTALLATION SERVICE/METER USE: �6 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. FILL OUT REVERSE S/DE OF THIS FORM. COPITACY It11F06iIVIATLOfd OWNER fi�,4ME: (/L � � � TEfV�,NT NAME (If Commercial): OWNER MAILING ADDRESS: srREEr CITY STATE ZIP OWNER PHONE: OWfVEFt EiV1.41L: COIUTRACTOR i�,4IVIE: ' COI�TRAC70R ADdRESS: sTREEr � � cirr sraTE � � ziP ' o CONTRACTOR PHOf�E: � � CO 7RACTOR EM�.IL: � COfUTRACTOR LIC.#(REc�UIRED): � C17Y OF EVERETT BUSIi� LIC.#(REQUIRED): �J PRIMARY CONTACT: ❑OWNER ❑ CONTRACTOR ❑ OTHER(Please Specify) COfiITAC7'fVAI�iE: COf�TACT PFiOf�E: � � �� Z� � ��6� �� 0�� `r�l��D COi�TACT EMAIL: � � � � a. G� AGREEMENT:The imdersigned applicant agrees to comp/y with a//provisions of the Everett Munrcipa/ ode 77t1e City of Ever t Otficial Use On(y 14 Water and Sewer or such ofher rules and regulations now existrng or which may be established fram time to FEE time. The applic�nt furthei ayrees, a condiTf n precedenf to receiving service fhat the utilities division shall have �� the rrght at any e,w' f notic , to si�ut otf o tum on the water supply for repairs, construcfion, and �� nonpayment f ch re s o� or an ofher reasona le cause.I am fhe owner, or I am authorired by fhe owner of this propeltyto p orn he wo r hich applicatio is made,and I comply with the State Con6actors Law 98.27 PERMIT# RCW and 29�200 WAC � _ ° �----�' �� /�� wner/Authoriz gent Sig ature Date (Revised 10/12/2015)