2130 CEDAR ST 2018-05-14 - Laserfiche WebLink

Y1�� / ��8�� 9��'�� 3�'- �'��i�I�Al1 CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P) 425-257-8810 � FAX 425-257-8857 � (E) everetteps@everettwa.gov � www.everettwa.gov/permits PROJECT �ITE INFOItMATIOPI PROJECT ADDRESS: ` IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF U5E? NO ❑ YES, FROM TO UTILITY APPLICATION INFORN914TION SEWER(check all that apply) WATER(check all that apply) ❑ SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION ❑ SIDE SEWER ALTERATION ❑ COMPLETE SERVICE ❑ METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: �I 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 SERVICE TYPE/SIZE: (circle desired size) ❑ I 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 ❑ DOMESTIC/FIRE COMBO: 1", 2", OTHER: SINGLE OWNERSHIP. F/LL OUT REVERSE SIDE OF TH1S FORM. CONTACT INFORMATION OWNER NAME: �l TENANT NAME(If Commercial): OWNER MAILING ADDRESS: sTReer CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: CONTRACTOR ADDRESS: sTReeT V ��7y STATE �, • ZIP CONTRACTOR PHONE: � CO TRACTOR EMAIL: CONTRACTOR LIC.#(REc1UIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED): O __ ,_..,... PRIMARY CONTACT: ❑OWNER ❑ CONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: � (,,t 5•�b Z � �a�,`I��j �� ,"�� CONTACT EMAIL: vvv AGREEMENT:The undersigned applicanf agrees to comp/y with all provisions of the Everett Municipal Code Title City of Evereff Official Use Only 14 Water and Sewer or such other rules and regulations now existing or which may be established f�om time fo FEE time. The appficant further agrees, a con �' n precedent to receiving service that the ufilities division sha/l have /�Q the right af any ' e,w' t notic , to shut off o turn on the water supply for repairs,construction,and �O V/ nonpayment f ch r s or or an otherreasona le cause.l am the owner,or I am authorized by the owne�of this property to p or he wo hich applicatio is made,and I comply with the State Contractors Law 18.27 PERMIT# RCW and 29 200 WAC /j � I r _ � I �, �� lJ� wner/Authoriz gent Sig ature Date (Revised 10/92/2015)