2709 CALIFORNIA ST 2018-01-12 - Laserfiche WebLink

. Wa�`��R / S��R �°�I�I`�Y ��I��'I�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 PROJEC7 SITE ItdFARM/�TIOId PROJECTADDRESS: /�^G` i;- �� 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� UTILITY APPLIC�►TION 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 7YPE/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 INFORMATION OWNER NAME: ,�ti��jC' l'�i�,rv/C/`�'�C-��f-�I TENANT NAME(If Commercial): OWNER MAILWG ADDRESS: sTREET r� Z— ��i� ! if}`/' � CITY �!� G�� STATE G'"�/ ZIP �'✓�'�� OWNER PHONE: OWNER EMAIL: CONTRAGTOR NAME: CONTRACTOR ADDRESS: sTReeT CITY STATE ZIP CONTRACTOR PHONE: CONTRACTOR EMAIL: CONTRACTOR LIC.#(REc1UIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED): _.._. _�.:..,.�_:._ . ._..._. __._. ..._ ., . . PRIMARY CONTACT: ❑OWNER ❑ CONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: CONTACT EMAIL: AGREEMENT:The undersigned applicanf agrees to comply with al!provisions of the Everetf Municipal Code Title Cify of Everett Official Use Only 14 Wafer and Sewer or such other rules and regulations now existing or which may be established from time fo FEE fime. The applrcant further agrees, as a condition precedent to receiving service that the utilities division shall have �� the right at any time,without notice,to shuf off or furn on the water supply for repairs,const�uction,and nonpayment of charges or for any other reasonable cause.I am fhe owner,or I am authorized by the owner of this property to perform the work for which application is made,and I comply with ihe Sfate Contractors Law 18.27 PERMIT# (� RCW and 296.200A WAC. � � O�( x , , ��v��rv�'�� S' �'� � ��O S � v Owner/Authorized Agent Signature Date (Revised 90/92J2095)