2702 21ST ST 2018-05-15 - Laserfiche WebLink

, �I� �V[�G� � �� r! �G�3 M�1 OL�0�!'� �G�'�Q� n,`��M� , �� CITY OF EVERETT PERMIT SERVICES � 3200 CEDAR STREET, EVERETT, WA 98201 (P)425-257-8810 � FAX 425-257-8857 � (E) ever2tteps@everettwa.gov � wvvw.everettwa.gov/permits [�fP3oOJC�C�i� �D�i I� ��I�oO�Gt��`�� PROJECT ADDRESS: � Cj 2 S �r IF�,PPLICABLE: ❑OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT# BUILDIiVG TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CNAfVGE OF U5E? � NO ❑YES, FROM TO llJ1 I`1'D�O��P Ql�'�'f�0��`�'0�� OG��f��f]iG�1`�O�G'�' SEVVER(check all that apply) �!lA�t'ER(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: ❑ 51DE SEWER RECONNECTION ❑ COMMERCIAL MULTIPLE DOMESTIC WAl'ER SERVICES REQUES7 WATER SERVICE TYPE/SIZE: (circle desired size) ❑ I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR ❑ DOMESTIC: 314", 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 TH1S FORM. CO�d'T/�C�' 9�9�ORMA`i'IORJ OWNER tJAME: TENAPdT iVAME(If Commercial): OWiVER IVIAILING ADDRESS: sTREET CITY STATE ZIP OWNER PHONE: OlNPVER EiViAiL: COfVTRAC70R PdAME: � � COIVTRACTOR.4DDl?ESS: sTREE� � �� N°� � a CITY , STATE � � ZIP �, � CONTRACTOR PHOfVE: � CO TRACTOR EiVIA1L: I� � P o �� CONTRACTOR LIC.#(RECIUIRED)v �i� � �� C17Y OF EVERETT BUSIN�S LIC.#(REQUIRED): � _._._.._._, PRIMARY CO�ITACT: ❑OWNER ❑ CONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: COfVTACT PHONE: �7 �� � �}�' � ' �,J �v� �� I�� u�� co�vrAc-r E��ai�: � � � �� ✓a o � J� AGREEMENT:The undersigned applicant agrees fo canply with all provisions of the Everett Municipal ode Title Cify of F_ver f Otficial Use Only 94 Water and Sewer or such other rules and regulations now existing or which may be established f�om time to FEE time_ The applicanf fi�ither ag�ees, S�a cond� precedent to receiving se�vice t(iat the utiliiies division shall have � the�ight at any ' e, w t notic , to shut otf o tum on the water supply for repairs, construcfinn,and �3�'�� nonpayment f ch r s or o�an other reasona le cause.I am the oia�ner,or I am aufhorized by the owner of fhis property to p��(((forn he wo � �hich applicatior�is made,and I comply�vith the Sfate Contractors Law 18.7_7 PERMIT# RCW and 29�200 WAC \�� p� , , � ��c� - 0� ' � - �.__.._.._.. � � wner/Authoriz� gent Signature Date (Revised 10/92/2095)