3110 18TH ST 2018-01-05 - Laserfiche WebLink

1�9Q`�� / �C��I�f� �1`�af�0�� ,f�6�L��`�O�N� 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 Pii0.7EC`�'S1�'� IN��12�1ii�`�'9�N PI20JECT ADDRESS: �� "' � '�J� � IF APPLICABLE: ❑OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT# BUILDING TYPE: ❑SFR-0ETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? �NO ❑YES, FROM TO lJTll.l'�Y APPLICA'YlOtm9 IfalFO�M/�`TI�� SEVV�R(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 DECLWING MULTIPLE DOMESTIC WATER SERVICES FOR ❑ DOMESTIC: 3/4", 1", 2", OTHER: MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ IRRIGATION: 3/4", 1", 2", OTHER: ❑ 1 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: �� TENANT NAME(If Commercial): OWNER MAILING ADDRE S: srREEr /� -� ` CITY STATE Z�P � OWNER PHONE: Z �� O OWNER EMAIL: � .,..__j�:�.�.... .,. _,.,.. ._.__ ........,�.. ._�._�..._w,w_ ,. CONTRACTOR NAME: C-, � CONTRACTOR ADDRESS: sTREer�� GN �V� STATE �� ZIP �LJ CONTRACTOR PHONE: �` �- CONTRACTOR EMAIL: CONTRACTOR LIC.#(RECIUIRED): `OQ CITY OF EVERETT BUSINESS LIC.#(REQUIRED): ,._,�.�._:T..�_.__.,..�_.m . ...,...,..,_�._,.. ___ ...��........ ._ _. . PRIMARY CONTACT: OWNER ❑CONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: Z � �,g --� ,'�' %�b� �� CONTACT EMAIL: t�� AGREEMENT.'The undersigned applicanf ag�ees to comp/y with aIl provisions of the Everett Municipa/Code Title City of Everett Offcial Use Only 94 Waterand Sewerorsuch otherrules and regulations now existing orwl�ich maybe esfablished from time to FEF_ time_ The applrcant further ayrees, as a condition p�ecedenf to receiving service that fhe utilities division shall have �� the righf at any time,v✓ithout notice,to shut off or tum on the water supply forrepairs,construction, and ��1 nonpayment of charges or for any other reasonable cause.1 am the owner, or 1 am aufhorized by the owner of this �L property fo perform e wo�k for which application is made,and 1 comply with the State Contractors Law 18.27 PF_RMI r# RCW and?_96. A AC_ � ,� I .�� l'a �-3 -- '7 � _' Ow e ufhorized Agent Sign fure Date (Revised 10/92/2015)