1912 LOMBARD AVE 2018-05-15 - Laserfiche WebLink

, � �V� � ��R i ��VV�� TII�I`�Y ��ICA�'ION 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 PROJEC7 SI7'E INFORMATION PROJECT ADDRESS: 2 IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT#_ BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? NO ❑YES, FROM TO UTILITY APPLICATIOtoI INFORMATION 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. ❑ IRRIGATION: 3/4", 1", 2", OTHER: ❑ I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑ F1RE: 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 THIS FORM. CONTACT INFORMATION OWNER NAME: TENANT NAME(If Commercial): OWNER MAILING ADDRESS: srReeT C�'Ty STATE ZIP OWNER PHONE: OWNER EMAIL; CONTRACTOR NAME: CONTRACTOR ADDRESS: sTReET y CI7Y STATE a • ZIP CONTRACTOR PHONE: � CO TRACTOR EMAIL: CONTRACTOR LIC.#(REc1UIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED): Q __. _..__.._ . PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: � CONTACT PHONE: � I•� ��'b Z, ��lj �,�� Y�,''�� CONTACT EMAIL: AGREEMENT:The undersrgned applicant agrees to comply with all provisrons oithe Evereft Municipal Code Tifle City of Evereff Offic:ial Use Only 14 Waterand Sewerorsuch ofher rules and regulations now existing orwhich may be established from time to FEE time. The applicant further agrees, a con i" precedent to receiving service that the utilities division shall have O the right at any ' e,w' t notic , to shut off o turn on the water supply for repairs,construction, and �7� O O/ nonpayment f ch r s or or an other reasona le cause.l am the owner, or l am authorized by fhe owner 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 // � � I I � I � � � � � ( _ �� `� � � � wner/Authoriz gent Sig ature Date (Revised 10/12/2015J