10923 3RD DR SE 2018-02-23 - Laserfiche WebLink

_ 1NA`��R / ��W�� I`�l�f ��`�10� 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 PROJECT SIYE INFORMA7'ION PROJECT ADDRESS: j� 7 i C, � J �- IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑GOMMERCIAL ❑INDUSTRIAL CHANGE OF USE? ❑ NO ❑YES, FROM TO UTILITY APPLICATION INFORIVIATION SEWER (check all that apply) WA7ER(check all that apply) IDE 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 SlDE OF THIS FORM. CONTACT INFORMATION OWNER NAME: � I {�C> � S^'l I � TENANT NAME(If Commercial): OWNER MAILING ADDRESS: sTReeT 5Ct V'+e CITY STATE Z�P OWNER PHONE: OWNER EMAIL: _......�. ._ .___ ._ . _,._, _.._. . ..._:.._... . CONTRACTOR NAME: 1 t(i�Z% r CONTRACTOR ADDRESS: srREer 'Q -S u�� . I�c. � J.� CITY � I�-� ✓ I� STATE `i�! °'+ ZIP `�I�CI CONTRACTOR PHONE: tI Z-�" ` '-C.:�1 Z� CONTRACTOR EMAIL: ' � 7 ZL CONTRACTOR LIC.#(RE[�UIRED): �CUr �,5� Z z ( CITY OF EVERETT BUSWESS LIC.#(REQUIRED): C� �PRIMARY CONTACT: �❑OWNER CONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: �� Z�� 3��, -t.(� � '� � i CONTACT EMAIL: AGREEMENT:The undersigned applicant agrees to comply wifh all provisions of the Everetf Municipa!Code Tit/e Cify of Eve�ett Official Use Only 14 Water and Sewer or such other rules and regulations now exisfing o�which may be established from fime to FEE time. The applicant further agrees, as a condition precedent to receiving service that the utilities division shall have � the righf at any fime,without notice,to shut otf or turn on the water supply for repairs,construction,and � nonpaymenf of charges or for any other reasonable cause.!am the owner,or 1 am authorized by the owner of this property to perform the work for which application is made,and I comply with fhe Sfate Contracfors Law 18.27 PERMIT# RCW and 296.200A WAC. � I �( � r �'�/`1� �-___- � rr Z � �.. Owner/Au ¢ed Agent Signature te (Revised 10/?2/2015J ��.