3620 BROADWAY 2018-01-05 - Laserfiche WebLink

. w�� i �Ew�� u�iLi-rY ��Li��-riorv 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 SITE INFORMATION PROJECT ADDRESS: 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 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��,�r�_� (��`, ❑ 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 THlS FORM. CONTACT INFORMATION OWNER NAME: TENANT NAME(If Commerciai): OWNER MAILING ADDRESS: sTReET CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: CONTRACTOR ADDRESS: sTREEr CITY STATE ZIP CONTRACTOR PHONE: CONTRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED): PRIMARY CONTACT: ❑OWNER ❑ CONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: CONTACT EMAIL: AGREEMENT:The undersigned app/icant agrees fo comp/y with a//provisions of the Everett Municipa/Code Tit/e City of Everett O�cia/Use Only 14 Water and Sewer or such otl�e�rules and regulations now exisfrng or which may 6e established from time to FEE time. The applicant further agrees, as a condition precedent to receiving service that the utilities division shall have �� _,_—,.__._ the right at any time,without notice,Eo shut off or turn on the water supply for repairs,construction,and � nonpayment of charges or for any other reasonab/e cause. 1 am the owner,o�I am authorized by the owner of this property to perform the work for which application is made,and l comply with the State Contractors Law 18.27 PERM�T# a d 2 6.2 �C_J / /� ` ' / � V Q��z�� -� J �� Owner/Authorized Agent Signature Date (Revised 10/12/2015)