5616 BEVERLY LN 2018-04-19 - Laserfiche WebLink

W� ER / SEWER 11TILITY �LICATION CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 {P)425-257-8810 � FAX 425-257-8857 � {E)everetteps@everetiwa.gov � www.everetiwa.gov/permits � . _. ,.. � � .. - h PROJECT SITE INFARMATION PROJECT ADDRESS: '"(o h , ,�� '3 IF APPLICABLE: ❑OUTSIDE CITY LIMITS BUILDING AREA SF ❑ LOT# BUILDING TYPE: ❑SFR-DETACHED FR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAI. CHANGE OF USE? J�Na ❑YES, FROM TO UTILITY APPLICATION INFORMATION SEWER(check all that apply) WATER(check all that apply) �IDE SEWER REPAIR ❑NEW WATER SERVICE INSTALLATION ❑SIDE SEWER ALTERATION ❑ 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 SERVtCE TYPE/SIZE:{circle desired size) � I AM DECLWING MULTIPLE DOMESTIC WATER SERVICES FOR ❑ DOMESTIC: 3/4", 1", 2", OTHER: MY MULTI-FAMILY DEVELOPMENT UNDER SWGLE 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: SWGLE OWNERSHIP.F/LL OUT REVERSE SIDE OF TH/S FORM. _ _ �, . _ ' ' CONTACT INFORMATION OWNER NAME: TENANT NAME(If Commerciai): OWNER MAfLING ADDRES : s-rR�r " �� , G�Jr( , CffY STATE �_ ZIP OWNER PHONE: c� �'j OWNER EMAIL: CONTRACTORNAME: �^ a I� � CONTRACTOR ADDRESS; s-rReEr d' "— CITY STATE U[� ZIP (�� CONTRACTOR PHONE: aS a CONTRAGTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): � C1TY OF EVERETT BUSINESS LIC.#(REQUIRED): b PRIMARY CONTACT: ❑OWNER ❑CONTRACToR ❑OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: as' � _.--�' ` �� CONTACT EMAIL: AGREEMENT.•The undersig d ap cant agrees to comply wifh all provisions of the Evereft Municipal Code Titie City of Evereft Official Use Only 94 Water and Sewer or such ot er rules and regulations now existing or which may be estabtished from time to FEE � fime.The applicant further agrees,as a condition precedent to receiving service that the uiilities division shall have the right af any time,without nofice,to shut off or furn on the water supply for repairs,construction,and ��-� nonpayment of charges or for any other reasonab/e cause.1 am the owner,or I am aufhorized by fhe owner of this property to perform the work for which application is made,and 1 comply with fhe State Contractors Law 98.27 PERM IT# �� RCW and 296.200A C. � � � � /'� � � � �� l�J Owner/Authorized Agent ignafure Date (Revised 10/92/2095)