415 61ST ST SE 2018-04-25 - Laserfiche WebLink

�/�� 9 �� 9S� � 9 AI�A� ��l��ll�� C(TY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 9820� (P)425-257-88�0 � FAX 42�-257-8857 � (E) everetteps@everettwa.gov� www.everettwa.gov/permits , _ _ , , _ _ . ' PR�JE�7' SITE II��ORMA7'101� :. . PROJECTADDRESS: �/ �oj(Sa- S �� IF APPLICABLE: ❑OUTSIDE CIiY LIMITS ❑ BUILDING AREA SF ❑ LOT# BUILDING TYPE: SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRiAL CHAIVGE OF USE? ❑NO ❑YES, FROM TO � . ,. .... ._ . . UTILITY APPL9CATIOM INFORNI,I�.TION = SEWER(check all that apply) WATER(check all that apply) L�SI.DE SEWER REPAIR ❑NEW WATER SERVICE INSTALLATION ❑S(DE SEWER ALTERATION ❑COMPLETE SERVIGE ❑METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER US�: ❑ INSTALL BACKWATER VALVE(outside the building) ❑SFR ❑SIDE SEWER CAP-OFF ❑MULTI-FAMILY-#OF UNITS: ❑SIDE SEWER RECOIVNECTION ❑COMMERCIAL MULTIPLE DOMESTIG WATER SERVICES REQUEST WATER SERVICE 7YPE/S1ZE:(circle desired size) L7 t 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 ❑pOMESTIC/FIRE COMBO: 9", 2", OTHER: SINGLE OWNERSNIP.FILL OUT REI/ERSE SIDE OF THIS FORM. ._ . _ .. , _ . . .. . . ... . . . ... .. .. . . ...:. ..... . : _ CONTACT 1NFORMATION . - . OWNER NAME: l,t.,� y �Ct, � TENANT NAME(If Commercial): OWNER MAILING ADDRESS: s-rR�r �/�j � �S� 5'�' �� CffY �-p/�� ` � STATE ZIP (�'YLd OWNER PHONE: �� 'r?° �� OWNER EMAIL.: �.R..:.��,,�.._.u4nu,.,n__�..._. .�� .... ...u....z...�_�..,,_.,...n.,�� .. ..,...>_�.........:..�. - - - - CONTRACTOR NAME ��L� � �C�U �� CONTRACTORADDRESS: srae�r ,e.d Y �a�.e� j �C� � � � � CITY C/ �� C STATE ZIP CONTRACTOR PHONE: 2� � � �� 22 CONTRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): �C S u� ��` CITY OF EVERETT BUSINESS LIC.#(REQUIRED): " `� �i�'S� PRIMARX CONTACT: ❑OWNER CONTRACTOR ❑OTHER(Please Specify) CONT CT NAME: f CONTAGT PHONE: �� '�� .��Z �U,�� "��S l� (� CONT�ICT EMAIL: AGREEMENT.-The undersigned applicanf agrees to comply with al!provisions of the Everett Municipal Code Title Cify of E'verett O�cial Use Only 14 Waterand Sewer or such other rules and regulafions now existing or which may be established from time to FEE � time.The applicant further agrees,as a condition precedenf to receiving service that the utilities division shall have /f /a ,�_ fhe rrghf af any time,without nofice,to shut off or furn on the water supply for repairs,construction,and % U nonpaymenf of charges or for any other reasonable cause.I am the owner,or!am authorized by the owner of this property to perform ork for which application is made,and i comply with the State Coniractors Law 98.27 PERM IT# RCW an . A . � ,,�� C '� �� �l OwnerlAut orized Agent Signature Date (Revised 90/9?J2095)