1916 GRAND AVE 2022-04-18 - Laserfiche WebLink

�� 4 ��CG� � �LN�n�1�G�3 �J1��L��1r � _[�p[�0�'�',�`�DO� , � CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P)425-257-8810 � FAX 425-257-8857 � (E) everetteps@everettwa.gov � www.everetfwa.gov/permits fP'l!'3��1JC�C�1� �0`l�l� 01�'G�OI��'1iLa��f� � PROJECT ADDRESS: / IF APPLfCABLE: ❑ OUTSIDE CITY L�M1T5 ❑ BUILDiNG AREA SF ❑ LOT# BUILDINGTYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OFUNITS: ❑COMMFRCIAI_ ❑INDUSTRIAL CFiANGE OF USE? � �� ❑YES, FROM TO M`�0�0111`�LQ�'�LO�L�1�0�1� 01��1�33Glf�Q�DoOG'� S�WER (check all that apply) 11VATER(check all that apply) ❑ SIDE SEWER REPAIR ❑ f�EW WATER SERVICL INSTALLATION ❑ SIDE SEWER ALTERATION ❑ COMPLETE SERVICE ❑ METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: �INSTALL BACKVI/ATER VALVE(outside the building) ❑ SFR ❑ SIDE SEWER CAP-OFF ❑ MULTI-FAMILY-#OF UNITS: ❑ SIDE SEWER RECONNECTION ❑ COMMERCIAL MULTIPLE DOIVIESTIC WA'TER SERVICES REQUES'T 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. ❑ IRRIGATION: 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. FILL OUT REVERSE SIDE OF THIS FORM. ��1'�/�CT' 9@a9�ORPViA�T90R8 OlIVJfdER NAME: TEPVAPdT PVAIVIE(If Commercial): OWIVER MAILIPIG ADDRESS: sTREET ��7y STATE ZIP OINNER PHOIVE: OWPVER EMAIL: --_ .,._.. .:---- . .._,..... .... ....._.... ......_.. �_ _� .. COiVTRACTOR tUAME: �� n COPdTRACTOR.4DDRESS: sTREer �j � �° � ��r � � CITY � STAT� �� ZIP CONTRACTOR PHO�IE: � �� CO TR�.CTOR EfV1AIL: I p e�/ � � � o � COPVTRACTOR LIC.#(RECZUIRED): , �i� � � � �, CISY OF EVERETT BUSIftI� LIC.#(RFc2UIRED� � . _. _..._ _ PRIMARY CONTACT: ❑OWNER ❑ CONTRACTOR ❑ OTHER(Please Specify) CO►VTACT AIAME: o COPNTACT PHOME: ��`� , ��7 ''G ��_�� �U �� '�� COiV7ACf EIUTAIL: � � � `��/ � �d�4a 0� ✓ E �� AGREEMENT:TAe undersigned applicant agiees io cornply wifh all pravisions of the Everett Municipal ode Tifle � Cify of F_ver f Official Use Only 14 Water and Sewer or such other rules�nd regulations now existing or which may be established from time fo FEE � time. The applicant fu�ther'agrees, Sra cond'i�n precedent fo receiving service that the utilities divrsion shaU have the right at any ' e, v✓ t notic ,to shut off ok turn on the water supply for repairs, construcfion, and �� j nonpayment f ch r s or or an other reasona le cause_l am the owner,or I am aufhorized by the owner of fhis �� property to pe fon he wo ✓hich applicafio�is made,and l comply ia�ith the Sfate Con[ractors Law 1 F327 PFRMIT# RCW and 29 ?_00 WAC - ' �`� , � ��' � I� a�—�� wner/�uthoriz� gent Sig�aturc Date: (Revised 90/12/209.5)