2031 MCDOUGALL AVE 2022-05-03 - Laserfiche WebLink

W� �R / S�1lV�R ��I�I`�� 1�a4�°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 PROJECT SI`fE INFORMATION PROJECT ADDRESS: 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 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 ❑ 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. CONTACT INFORMATION OWNER NAME: TENANT NAME(if Commercial): OWNER MAILING ADDRESS: srREer C�7y STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: CONTRACTOR ADDRESS: srREEr y CITY STATE � • ZIP CONTRACTOR PHONE: '� CONTRACTOR EMAIL: CONTRACTOR LIC.#(RECIUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUIRED): D PRIMARY CONTACT: ❑OWNER ❑CONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME; CONTACT PHONE: '� � �ib Z �� ,~� CONTACT EMAIL: AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title Cify of Everett Official Use On/y 14 Vl/ater and Sewer or such other rules and regulations now existing or which may be established from time to FEE fime_The applicant further agrees, a con �'n precedent to receiving service that the ufilities division shall have I' ^ D /� the right at any ' e,w t notic ,to shut off o tum on the wafer supply for repairs,construcfion,and �� 1� ��j nonpayment f ch r s or or an other reasona /e cause.I am the owner, or I am authonzed by fhe owner of this � � � ' property to p for he wo hich applicafio is made,and I comply with the State Contractors Law 18.27 PERMIT# RCW and 29 200 WAC _ � � � � `' �� �-__._-- - "� 1 I l� � wner/Authoriz gent Sig ature Date (Revised 90/17l?_015)