1601 GRAND AVE 2018-01-18 - Laserfiche WebLink

�Q`��I� � �C�L� M`��[�0�� ,pf�f�d�l��8�� CfTY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P)425-257-8810 � FAX 425-257-8857 � (E) everetteps@e�erettwa.gov � www.everettwa.gov/permits _ PriO.J�C`�' SI�'� 0��fVa�1'�'0��1 PROJECTADDRESS: !�^�"j� -�r� �h/Z 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? �N� ❑YES, FROM TO �97'IY.17"Y �►PPLICA`�'101�➢ I�IFOIZMA`TIOPd SEWER(check all that apply) WATER(check all that apply) �SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION ❑ SIDE SEWERALTERATION ❑ 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) C�1 I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR ❑ DOMESTIC: 3/4", 1", 2", OTHER: MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. ❑ �RRIGATION: 3/4", 1", 2", OTHER: ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑ F1RE: 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 Commercial): OWNER MAILING ADDRESS: srREET CITY STATE Z�P OWNER PHONE: OWNER EMAIL: CONTRAC70R NAME: ��j� •� �.�,! ,5�� f kv+n �� CONTRACTOR ADDRESS: srREEr '' j. .S W .'41 k.� i� r �� STATE',�,.i� -��y�; '�t}. ZIP �� U�j � CITY C� .-}- ' CONTRACTOR PHONE: � (5F; 'Yt - (77 CONTRACT�R EMAIL: CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC #(REQUIRED : O , ....�...:-. ��.. .,.r. .�.,._,_�. ..... _ ..r PRIMARY CONTACT: ❑`OWNERy I�CONTRACTOR ❑ OTHER(Pfease Specify) �� CONTACT NAME: CONTACT PHOIVE: CONT,4CT EMAIL: AGREEMENT.'The undersrgned applicant agrees to comply wifh all provisions of fhe Everett Municipal Code Title City of Everetf Offcial Use On/y 14 Vi/afer and Sewer or such other rules and regulations now existing or which may be esfablished from fime to FE� time. The applicant fu�ther agrees, as a condifion precedenf to receivinq service that the utilifies division shall have � the right at any time,witl�out notice,fo shut off or turn on fhe wafer supply forrepairs,construction,and �— nonpayment of charges or for any other reasonable cause.1 am fhe owner,or I am authorized by the owner of this property to perform tlie wo�k for which application is made,and 1 comply with the Sfate Confractors Law 18.27 PERMIT# /� 1 RCW and 296��/VAC. � 1� �( U � �_-i �--_.' _ i I��7 ��v�7 ` d ��'- � Owner/Authorized Agent Signature Date (Revised 10/12�2015)