8119 BEVERLY BLVD 2018-01-17 - Laserfiche WebLink

1NA`�ER / ��1�� TI�I`�Y ��IC�a`�ION 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: j � �'�c�I i-- ��I L'C� L=L)��ti E 't'� t�-�/� i'�J�'' '�J ".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 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 ❑ 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", �THER: 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: �% ,� C� �i �� i�'�/!� TENANT NAME(If Commercial): OWNER MAILING ADDRESS: sTREer �%� �� ;�' ��';`1�' i�71�;C� ciTv F=�l;>�� • sTnTe �� ziP ��<a� OWNER PHONE: ' ��•�" OWNER EMAIL: /V � _>...-.�,_._._. ._... _... _. _._._.._.. . �.. . ,:... �._,... ... ,._.. . ..._ � .. ._ , CONTRACTOR NAME: �')��y—G"l C��'� 3 Iv�'1'1��V�� CONTRACTOR ADDRESS: sTREeT ��'1 C�.► Sc�� /-}��'� "�� CITY �G'�"I-'I �_ STATE t/�„� 1 ZIP �- ��.- � CONTRACTOR PHONE: ,�Z "; , �� .>L 1 7� / CONTRACTOR EMAIL: � =� � CONTRACTOR LIC.#(REQUIRED): ��:� 1 HI/1�1n .,.-� .. C".. . . . .._,.__ . _..... ___...___ ........: .. ........� . .:. ,.�.. �.. _.....: ..._. .�... �(_.�- ..::_.., , CITY OF EVERETT BUSINESS LIC #REQUIRE ) ^ ._.._. _._,._,__._.. .........., PRIMARY CONTACT: ❑OWNER ❑ CONTRACTOR II�'�THER(Please Specify) `��'�'%� = CONTACT NAME: CONTACT PHONE: , 'G �-�r=� �-�� •�� ' CONTACT EIViAIL: / �''�,UL„/ 1��.}��.��s �� /�) � AGREEMENT.�The undersigned applicanf agrees to comply with all provisions of the Everett Municipal Code Title City of Everetf Official Use Only 14 Water and Sewer or such other rules and regulations now existing or which may be esfab/ished from time to FEE time. The applicant further agrees, as a condition precedent to receiving service that fhe utilities division shall have the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and nonpayment of charges or for any other reasonable cause.1 am the owner,or I am aufhorized by fhe owner of this property to perform the wo�k for which applicafion is made,and 1 comply with fhe Stafe Contractors Law 1 f3.27 PERM IT# � RCW and 29 A WAC/ � �� f � `�t � �-�� "z--, �� I�.�� ,-� ` � Owner/Authorized Agent Signature Date (Revised 10/12/2095)