4915 GLENWOOD AVE 2018-05-16 - Laserfiche WebLink

�i��i �� A �C�IC� M�'QI�B`�� Q�I�L��fl�� 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_gou/permits P@�OJ�C�' Si`�'� iG��Rt1ii�'�'�� PROJECT ADDRESS: 4� I�j I �'1�6 VC t � IF APPL(CABLE: ❑ 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 ��'ILITY APPLICA`YIO1� INF01�M�1"1'IOId SEWER(check all that apply) WATER(check all that apply) �SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION ❑ SIDE SEWERALTERATION ❑ COMPLETE SERVICE ❑ METER ONL.Y ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: ❑ INSTALL BACKUVATER 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) M 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: ❑�1 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. F/LL OUT REVERSE SIDE OF THIS FORM. ' CONTACT INFORMATION OWNER NAME: TENANT NAME(If Commercial): OWNER MAILING ADDRESS: srREET CITY STATE ZIP OWNER PHONE: OWNER EMAIL• ,.�. _� ..•-- _....,......_._..� _�.,".._a... ..___,..�.......... , , CONTRACTOR NAME: F � CONTRACTOR ADDRESS: sTREer CITY STATE ZIP CONTRACTOR PHONE: �-o�s `-� �-3t33 COfVTRACTOR EMAIL: Q, �"�,Q,W L�L � CONTRACTOR LIC.#(REc�UIRED): CITY OF EVERETT BUSINESS LIC #(REQUIR ): PRIMARY CONTACT:` �OWNER' ❑CONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: aS ' 3� 3 \�Ob CO�ITACT EMAIL: v v�a �.�„�f�l(f��P�y�i� �, ►'�, r� AGREEMENT.'7he undersigned applicant agrees to comply with all provisions of the Everetf Municipal Code Title City o verett Official Use Only 94 Water and Sewer or such other rules and regulations now existing or which may be established from time to FE� O time. The applicant further agrees, as a condrtion precedent to receiving service that the utilities division shall have � �"� �/ the g y � ,without notice,to shut off or tum on the water supply forrepairs,construction,and U non ay e � ar es or for any other reasonable cau m the owner, or 1 am aufhorized by fhe owner of this pro rty orm the ork fo��,y,t6aeFr�pplicafion is made,and I comply with the State Contractors Law 18.27 PERMIT# r L V� � b RC an 9 20 �£" ' � "��7 . ��` � � � 7� `.i � Owner/Atrthorized Agent Signature Date (Revised 90/12/2095)