2621 GRAND AVE 2018-01-18 - Laserfiche WebLink

, �V�v�CG� � �CM��G� M�i OL�O`I��l �pf�Oc�Q`�DOO� ' �� CITY OF EVERETT PERMIT SERVICES o. . 3200 CEDAR STREET, EVERETT, WA 98201 (P)425-257-8810 � FAX 425-2�7-8857 � (E) everetteps@everettwa.gov � www.everettwa.gov/permits l�'�OJC��`lI' ��'� D�f��Vi�iQ�O�� PROJECI"ADDRESS: 2l(J?� IF,4PPLfCR�LE: ❑ OUTSIDE CI LIMITS ❑ BUILDING AREA SF ❑ LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHAPdGE OF USE? NO ❑ YES, FROM TO 1�J1��1�,��YQ�'�LOC�L�S�'0�� 01^��G�'11�.�0�� S�UVEI�(check all that apply) �lilA7�F�(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 BACKVI/ATER VALVE(outside the building) ❑ SFR ❑ SIDE SEWER CAP-OFF ❑ MULTI-FAMILY-#OF UNITS: ❑ SIDE SEWER RECONNECTION ❑ COMMERCIAL MULTIPLE DOlV1ESTIC WATER SERVICES REQUES7 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. ❑ �RRIGATION: 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. CO�➢'TAC�' O@a9FORMA�IOPd OWidER NAME: TEPVA�IT iVAME(If Commercial): OWNER MAILING ADDF2ESS: sTReer CITY S7ATE ZIP OV1/NER PHOIVE: OWfVER EfV1AIL_ COiVTRACTOR PlAME: � CONTRACTO�ADDRESS: sTREEr �S 9�r�� t CITY STATE � o ZIP �, COA1 I RACTOR PHOftIE: � ' CO TRRCTOR EMAIL: ,� �p �� P � ,� COPITRACTOR LIC.#(REQUIRED): ;�� CIfY OF EVERETT BUSIiV�LIC.#(REQUIRED� � PRIMARY COiVTACT: ❑OWNER ❑ CONTRACTOR ❑ OTHER(Please Specify) GO►VTACT NAME: CONTACT PFiOME: �� , Z'J l �,�1 �U �� COIVTACI'�iViAIL: `� � � �� l�a 0 � � B �' AGI�EEMFNT:7 he undersigned applicant ag�ees to comply with al!provisions of fhe Everett Municipa! ode Title City of Ever f Otficial Use Only 94 Water and Sewer or such other rules,`�nd regedafions now existrng or which may be established from time to �=EE time_ The applicant fuither agrees, Sra condi' prer.edent to receiving service that fhe utilifies drvision shall have v the right af any ' e, w t notic , fo shut orf n tum on fhe water supply for repai�s, constructinn, and � ��j „�.� nonpayment f ch r s or or an other reasona le cause.l am the owner, or I am authorized by the owner of this property fo p for he wo �hich applicatio is made,and I comply with tiie Sfate Contiactors Law 1 t3.7_7 PERMII # P,CW and 29 200 WAC .� M �� '�� -�� �wner/Aufhoriz gentSig afure Date (Revised90/12/2095)