2405 STATE ST 2018-01-04 - Laserfiche WebLink

v��l�� J ��w�� a�A�i�u-� ��rc��iorv 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 PROJECY S1�'E IN�ORM14T10N PROJECT ADDRESS: �I�/S �� t, � . `�'I'�� '�V��'� �'-'� C� �� I 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? NO ❑YES, FROM TO UTILITY APPLICATION INFORMATION SEWER(check all that apply) WATER(check all 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. F/LL OUT REVERSE SIDE OF THIS FORM. CONTACT INFORMATION OWNER NAME: c'� �J�'� C'�� TENANT NAME(If Commercial): OWNER MAILING ADDRESS: sTReeT Z � Z— ��' � Q CITY Q�`�- � STATE �' ` ZIP �Z CJ� j OWNER PHONE:�2�� j / � OWNER EMAIL: CONTRACTOR NAME: � � � CONTRACTOR ADDRESS: sTRee-r � CITY STATE Z�P CONTRACTOR PHONE: CONTRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED): ,.�.,� �:.._.�,_.. ,_. ,, ....,.._ . .. ._..�.. ,-..,.,:.. . .__.. , ....._.,_-. . ..�.....,._ _.,_.....__ ._ ..._._, . . ___..._.,_ : _ ._.. . _ .._ . PRIMARY CONTACT: ❑OWNER ❑ CONTRACTOR OTHER(Please Specify) �� 2 sc- t�� CONTACT NAME: CONTACT PHONE: �2� � � � �� C,( �vG�� CONTACT EMAIL: AGREEMENT:The undersigned applicant agrees to comp/y with a//provisions of the Everett Municipal Code Title Cify of Everett Offcial Use On/y 14 Water and Sewerorsuch other rules and regulafions now existing orwhich may be established from fime to FEE time. The applicant fu�ther agrees, as a condition precedent to receiving service ihat fhe utilities division shall have �j� the right at any time,withouf notice,to shut off or turn on fhe wafer supply for repairs,construcfion, and v � nonpayment of charges or for any other reasonable cause.I am the owner,or/am authorized by the owner of this property to perform the wo�k for which applicafion is made,and I comply with the Stafe Contractors Law 98.27 PERMIT# RCW and 296.200A WAC. � � � � I ��7, � O�� ' � v� Own r/Authorized Agent Signature Date (Revised 90/92/2015)