2001 MCDOUGALL AVE 2018-05-15 - Laserfiche WebLink

UV� �R / S��V�� T��I`�Y � �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 SITE INFORMI�TION PROJECT ADDRESS: C �/�, 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 APPLICATION INFORNiAT10N 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 ❑ 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: � �r TENANT NAME(If Commerciai): OWNER MAILING ADDRESS: sTREEr C�7y STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: CONTRACTOR ADDRESS: sTReer V CITY STATE a • ZIP CONTRACTOR PHONE: � CO TRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 4 PRIMARY CONTACT: ❑OWNER ❑ CONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: � (•� 5�b Z /��{�,`I'�lj ��l ��'�� CONTACT EMAIL: vvv AGREEMENT:The undersrgned appiicant agrees fo comply with all provisions of the Evereft Municipal Code Title Cify of Everett Official Use Only 14 Waterand Sewerorsuch ofher rules and regulations now existing orivhich may be established from time to FEE time. The applicant further agrees, a con �" n precedent to receiving service that the utilities division shall have Q fhe�ighf af any ' e,w" t notic , fo shut off o tum on the water supply fo�repairs,consfruction, and �O 6� nonpayment f ch r s or or an ofher reasona le cause.I am the owner,orl am authorized by the owner of fhis properfy to p or he wo hich applicatio is made,and I comply with the St e Contractors Law 18.27 PERMIT# RCW and 29 200 WAC _ � I � � i _Q�y � �,,,/ l l n wner/Authoriz gent Sig ature Date (Revised 90/17J2095)