3510 86TH ST SE 2018-04-05 - Laserfiche WebLink

WAmI R / SEWER UTILITY 1LICATION CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P)425-257-8810 I FAX 425-257-8857 I (E) everetteps@everettwa.gov I www.everettwa.gov/permits �� PROJECT SITE INFORMATION PROJECT ADDRESS: 5„f/ 7 )G •'" S T S et* e3 �l/cre J s r- Oc.J4, IF APPLICABLE: #1g4 OUTSIDE CITY LIMITS a BUILDING AREA 2l1+ct! SF 0 LOT# BUILDING TYPE: SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL 0 INDUSTRIAL CHANGE OF USE? KNO 0 YES, FROM TO UTILITY APPLICATION'INFORMATION a 3 . SEWER(check all that apply) WATER(check all that apply) ❑SIDE SEWER REPAIR ArNEW WATER SERM)CE INSTALLATION MF,t i 3&f2Vi et j Ntr ma DI FY C.4471CrAl or eaC s netacelmo ❑SIDE SEWER ALTERATION f1151 COMPLETE SERVICE ti sr"-euled X NEW SIDE SEWER INSTALLATION SERVICE/METER USE: ❑ INSTALL BACKWATER VALVE(outside the building) ,SFR ❑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) ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR DOMESTIC: ta 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 ❑_�DOMESTIC/FIRE COMBO: 1", 2", OTHER: SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. S`\AS%dim i /aOOSF ' - ahuier P rtc V �-Mfl'S Q- Clfiy r/jyf CONTACT INFORMATION . OWNER NAME: L2 yn¢,f r�?....4Kr.J TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET d p c y '7/�o STATE G'L ZIP Q(f-fid OWNER PHONE: ci r— "cf 2 2 if f OWNER EMAIL Ptyzefr lOk! ,A!?_ CONTRACTOR NAME: P Rex `Yv rr.1��9 CONTRACTOR ADDRESS: STREET 3$ r/ CITY U STATE ZIP �r.z—dcrd CONTRACTOR PHONE: teC f— rZZ-/4,k CONTRACTOR EMAIL:0yc r % IIr.ets*-/i4-2C tO /p 4c�, / iG CONTRACTOR LIC #(REQUIRED) C5/4¢,s 4, `t/lis CITY OF EVERETT BUSINESS LIC #(REQUIRED) PRIMARY CONTACT: OWNER ,CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: �I l,C .� y►G� CONTACT EMAIL: AGREEMENT:The undersigned applicant agree{to comply with all provisions of the Everett Municipal Code Title City of Everett Official Use Only 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to FEE 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 to perform the rk for which applicationmade,and I comply with the State Contractors Law 18.27 PERMIT# RCW and 296.200A 1. it? Owner/Authoriz•. Aget g ature Date (Revised 10/12/2015)