1920 MCDOUGALL AVE 2018-05-15 - Laserfiche WebLink

V�'! � i�R / S�UV�R �`�I�I�'� _ �� [�I�A�'I�N 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' SITE INFORMATION PROJECT ADDRESS: IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDINGAREA SF ❑ LOT# BUILDING TYPE: ❑SFR-QETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? 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: �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: (circie 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 ❑ F1RE: 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. CONTACT INFORMATION OWNER NAME: TENANT NAME(If Commercial): OWNER MAILING ADDRESS: sTReeT CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: CONTRACTOR ADDRESS: srReEr � CITY STATE � • ZIP CONTRACTOR PHONE: � CONTRACTOR EMAIL: CONTRACTOR LIC.#(REc�UiRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED): D PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: � � ��'b Z � I��,r��j �,�� ,'�� CONTACT EMAIL: vvv AGREEMENT:The undersigned applicant agrees fo comply with all provisions of the Everett Municipa!Code Title City of Evereff Official Use Only 14 Wafer and Sewer or such other iules and regulations now existing or which may be established f�om time to FEE time. The applicant further agrees, a con i' n precedent to receiving service that the utilities drvision shall have � �j� fhe�ight at any ' e,w" f notic ,to shut off o turn on the water supply for repairs,construcfion,and �D �" nonpayment f ch � s or or an other reasona le cause.l am the owner, or I am authorized by fhe owner of this property to p or he wo r hich applrcatio is made,and I comply with the State Contractors Law 18.27 PERMIT# RCW and 29 200 WAC � �� Q� / � � � �� �Pl� wner/Authoriz gent Sig ature Date (Revised 10/12/?_015)