12618 16TH AVE SE 2018-01-05 - Laserfiche WebLink

52 � 8 �- 70 �'° �9��1�� C�IGI� �JJ`�Dl��f� aG'G'(L,�C�/��'0�� � 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 �H��J��`Y 51�� 19dI��l6i�`�'��i�9 PROJECT,4DDRESS: � Z�p �� - � �� V� �SE _ 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 T� �'TIL9'�`l� APPLICA�'IOR9 ORI�'��A`�"IO�d SEVI/ER(check all that apply) -dItAT�R•(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. FILL OUT REVERSE SIDE OF THIS FORM. CONTACT INFORMATIOId OWNER NAME: --,\N� -�l ��E TENANT NAME(If Commercial): -r�rt � OWNER MAILING ADDRESS: srReer �Z�s� c� I� L SL- CI7Y � V C � l' STATE �� ZIP CJ Z� O OWNER PHONE:'rf 2 ' 4U3 ' 2 3� U OWNER EMAIL: �1 1'� . L- • C1��'��NL=� �C� NC , C�M .�.._....W,<.::,�.,.. .. ..... . ....... ..,. .. ._>>._ .. �.�.,,...�_... .,,_..... ,�.,.�..�» . .__. . � , . CONTRACTOR NAME: t �I L� � -� �.,- � CONTRACTOR ADDRESS: sTReer CITY STATE ZIP CONTRACTOR PHONE: COiVTRACTOR EiVIAIL: CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC #(REQUIRED): PRIMARY CONTACT: �,OWNER. ❑ CONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: COPVTACT PHOME: L�L2S , � O� ' Z V O U �� M Et�2`�� N�-fL.. CORITACT ElV1AIL: �t �. L - C�� fZ�C_3oL t 1�C� .c� AGREEMENT:The undersigned applicant agrees fo comply with all provisions of the Evereft Municipal Code Title City of Evereft Officia!Use Only 94 lNater and Sewer or such other rules and regulations now existing or which may be esta6lished f�om time to FEE /�, time_ The applicant further agrees, as a condition precedent to receiving service thaf the utilities division shall have � �'""�'�,�J f2 J Dv fhe righf at any time,witF�out notice,fo shut off or turn on the water supply for�epairs,consfruction, and I� JE�� nonpayment of charges or fo�any other reasona6(e cause.1 am the owner,or I am aufhorized by the owner of this property to perfo�m the work fo�which application is made,and!comply with the State Confractors Law 18.27 PERMIT# RCW��296 AWAC. � � � �� � c�� 8� / � O ner/Aufhorized Agent Signafure Date (Revised 10/12/2095)