2920 16TH ST 2018-04-16 - Laserfiche WebLink

00000.- WATER / E ! unurie APPLICATia , CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P)425-257-8810 FAX 425-257-8857 I (E) everetteps@everettwa.gov www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: ag9,0 1 Cpm EVE,-fir- WG c�aO\ IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL DINDUSTRIAL CHANGE OF USE? 133.NO ❑YES, FROM TO UTILITY APPLICATION INFORMATION. SEWER(check all that apply) WATER(check all that apply) VI SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION ❑SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: ❑ INSTALL BACKWATER VALVE(outside the building) 0 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 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: \r GwY1, G,WGN TENANT NAME(If Commercial): OWNER MAILING ADDRESS: sTREET 20 I`0o, ' - crry E've se# STATE tiJ cA. ZIP 1 J O= OWNER PHONE: A0Grq--1-1 OWNER EMAIL: CONTRACTOR NAME ]yv\ �C�,Y� ' f c l�c . P vomko h CONTRACTOR ADDRESS: STREET G a1 11‘ cry M,othh\-10,kci Tirvoce, W STATE 01. ZIP W0113 CONTRACTOR PHONE: aO(O- �I�f-(aC000NTRACTOR EMAIL: PCA-1-11'CIA CiCZ ��W1UC� 1 �' Go CONTRACTOR LIC.#(REQUIRED): ( )O - 451- L-133 CITY OF EVERETT BUSINESS LIC.#(REQ RED): 0 bco7oa PRIMARY CONTACT: ❑OWNER ($(,CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: /� CONTACT PHONE: �<p- L( - ,Qc,0 G�,`J1-r C V� l-7 GLV 111 O CONTACT EMAIL: P6t4Grk C'-�l&f i r40.0 r'cl1' ct e fir,cow \ AGREEMENT:The undersigned applicant agrees 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 work for which application is made,and I comply with the State Contractors Law 18.27 PERMIT# RCW an .2 I aLI l b Y I Owner/Authorized Agent Signature Date (Revised 10/12/2015)