2706 21ST ST 2022-05-18 - Laserfiche WebLink

�i lI E�G3 � �CMn�CG�3 lUJ`�OLO��( �p�.0�/�1��00 G� r � , �� CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P)425-257-8810 � FAX 4�25-257-8857 � (E) everetteps@everettwa.gov � www.everettwa.gov/permits �I�oO�DG6�( �0�t� O�I�oOf�3f�1��0�f� PROJECT ADDRESS: 2 � IF�4PPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILUING AREA SF ❑ LOT# BUILDING 7'YPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY�#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CNANGE OF USE? - NO ❑ YES, FROM TO llU`�'OL��i'1`�/��I�'�OC��'0�6� OIi��V�t76R1�0�1f� SEWER(check all that apply) 1iVATER(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 BACKVI/ATER VALVE(outside the building) ❑ SFR ❑ SIDE SEWER CAP-OFF ❑ MULTI-FAMILY-#OF UNITS: ❑ SIDE SEWER RECONNECTION ❑ COMMERCIAL MULTIF'LE DOIVIESTIC WA'TER SEf'2VICES R�QUEST 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 INSI-ALL 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 S1DE OF THIS FORM, CORI'�'/�1�� 9Pa9FORNSA��IOt� OWPVER NANIE: TENAPdT NAIVIE(If Commercial): OWPVER MAILIMG ADDRESS: siReEr �17Y STATE ZIP OWNER PHONE: O11U1JER EMAIL: �._._..._. . .._.��... __.... _..,._. .. .._. ..__ ,... --.,�.. , --- --.._.,__.. __._.._... _. .:.._ _. ___ ,,... . ._....__. __.._. COIVTRAC70R iVAME: � '� o CONTRACTOP.4DDRESS: sTREET � �� P�� � CI7Y STATE �� a ZIP �, COiVTRACTOR PFiOAIE: � �� CO TRACTOR EMAIL: �� Pj � � e g � CONTRACTOR LIC.#(REc1UIRED): � � � � � �, � CITY OF EVERETT BUSIfV� LIC.#(R�QUIRED): � PRIMARY CONTACT: ❑OWNER ❑ CONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: a CORITACT PFiOIVE: �`� , Z� "L �� �� COiVTACT ENiAIL: � ` � �� v�`@/a o� � AGREEMENT:The undersrgned applicant agrees to comply wifh all provisions of rhe Evzrett Municipal de Title Cify of Ever t Official Use Only 94 Wafer and Sewer or such other rules and regulations now existing or which rnay be established from time to FEE time_ 7he applicant fifrther agrees, S`�a con�d� precedenf fo receiving service that the uh7ities division shall have �� fhe right at any � e,w' t notic�to shut off ok turn on the wafer supply forrepaiis,constiuction, and l� �� nonpayment f ch r' s or or an other�easona /e cause.l am ihe o��ner,or I am authorized by the owner of this prope�ty to p forn hc wo �hich applicatio�is made,and l comply v✓ith the Sfate Cont�actors!_aw 9F3.?_7 PF_RMII # ��w��2��oa WA� .� i — � 1� o g -��0 , ; ., , t. � .: ., wner/Authoriz� , gent Sigi afure I_)ate (f�evised 90/12/?_095)