2021 LOMBARD AVE 2018-05-15 - Laserfiche WebLink

. vv� - _�� s�r�� i�i�� . �� a��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 PROJECT SIT'E INF01tMA7'IOPI PROJECT ADDRESS: O?j 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 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: �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 ❑ 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 THIS FORM. CONTACT INFORMATION OWNER NAME: TENANT NAME(if Commercial): OWNER MAILING ADDRESS: srReer CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: CONTRACTOR ADDRESS: srREEr y CITY STATE a • ZIP CONTRACTOR PHONE: '� CO TRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED): O PRIMARY CONTACT: ❑OWNER ❑ CONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: � CONTACT PHONE: � C•� 5•�'b Z ��j �� ,''�� CONTACT EMAIL: AGREEMENT:The undersigned applrcanf agrees to comply wifh all provisions of the Everetf Municipal Code Title Cify of Evereff Official Use Only 94 Water and Sewer or such other rules and regulations now existing or which may be established from time to time. The applicant further agrees, a c�on�i' n precedent to receiving service that the utilities division shall have FEE ��o� the righf at any ' e,w' f notic ,to shut off o fum on the water supply for repairs,construcfion, and nonpayment f ch r s or o�an other�easona /e cause.I am the owner, or I am authorized by the owner of this p�operty to p or he wo hich applicatio is made,and!comply v✓ith the Stafe Contractors Law 18.27 pERMIT# RCW and 29 200 WAC _ "� _ _�� L � � � l � L �'� 0 wner/Authoriz gent Sig ature Date (Revised 90/92/2095)