3214 NASSAU ST 2018-02-08 - Laserfiche WebLink

• 477 WATER / SEWER UTILITYYPPLICATION CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P)425-257-8810 I FAX 425-257-8857 1 (E) everetteps@everettwa.gov 1 www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: 3214 Nassau St., Everett IF APPLICABLE: 0 OUTSIDE CITY LIMITS ❑ BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: OCOMMERCIAL ❑INDUSTRIAL CHANGE OF USE? ❑ NO 0 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 0 METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: 0 INSTALL BACKWATER VALVE(outside the building) 0 SFR O SIDE SEWER CAP-OFF 0 MULTI-FAMILY-#OF UNITS: ❑SIDE SEWER RECONNECTION 0 COMMERCIAL MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE: (circle desired size) 0 I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR 0 DOMESTIC: 3/4", 1", 2", OTHER: MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. 0 IRRIGATION: 3/4", 1", 2", OTHER: ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER 0 FIRE: 1", 2", 4", 6", 8", OTHER: SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER 0 DOMESTIC/FIRE COMBO: 1", 2", OTHER: SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. CONTACT INFORMATION OWNER NAME: Providence Health & Services TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET 916 Pacific Ave. CITY Everett STATE WA 71P 98201 OWNER PHONE: 425-314-9432 OWNER EMAIL: lloyd.christensen@providence.org CONTRACTOR NAME: Wrecking Ball Demolition LLC CONTRACTOR ADDRESS: STREET 3310 Chestnut St. cI,,, Everett STATE WA zip 98201 CONTRACTOR PHONE:425-328-5104 CONTRACTOR EMAIL: mitchs@Wreckingballdemo.com CONTRACTOR LIC.#(REQUIRED):WRECKBD024NU CITY OF EVERETT BUSINESS LIC.#(REQUIRED):033727 PRIMARY CONTACT: ❑ OWNER CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: CONTACT PHONE:425-328-5104 Mitch Shoemaker CONTACT EMAIL: mitchs@wreckingballdemo.com AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to 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,to shut off or turn on the water supply for repairs,construction,and nonpayment of charges or for any other reasonable cause.I am the owner,or I am authorized by the owner of this property t perform the work for which application is made,and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC City of Everett Official Use Only !I,' f1 PERMIT# Owner/Authorized Agent Signature Date (Revised 9/23/2016)