2217 MCDOUGALL AVE 2018-05-30 - Laserfiche WebLink

` - WATER / SEWERUTILITY PUCAT ` /° CITY OF EVERETT PERMIT SERVICES -- 3200 CEDAR STREET, EVERETT,WA 98201 (P)425-257-8810 I FAX 425-257-8857 I (E) everetteps@everettwagov I www.everettwa.gov/permits 4r ' , �P R� .9 Wa IN�F M I®N r �,:�, � ��t- PROJECT ADDRESS: a a\1 G e1t Ave-Aire• �7 t 201 IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED,SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL DINDUSTRIAL CHANGE OF USE? '4 NO 0 YES, FROM TO LITY ALICATION .INPOlt1VIATION SEWER ... � .�-_ �, _ �_.�,.UTI_._ - -_.� .PP - (check all that apply) - WATER(check all that apply) XSIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION 0 SIDE SEWER ALTERATION ❑COMPLETE SERVICE 0 METER ONLY • • ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: ❑ INSTALL BACKWATER VALVE(outside the building) 0 SFR ❑SIDE SEWER CAP-OFF 0 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 0 DOMESTIC: 3/4", 1", 2", OTHER: MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. 0 IRRIGATION: 3/4", 1", 2", OTHER: ❑ 1 AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER 0 FIRE: 1", 2", 4", 6", 8", OTHER: SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER 0 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: STREET �C �� ✓ 1 / "� 1` 1 / CITY `-'`�''' STATE�,/1✓A ZIP ,g'j 1) I OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: ell; Lk( )57(IAcrla/3 U_C CONTRACTOR ADDRESS: STREET / 63j s (2-.0k CITY 't s STATE) ZIP l 5212 3 CONTRACTOR PHONE: L Z5-- a su - � �[/�CONTRACTOR EMAIL: J x C o1)5i-4,cp b ni � ;\ .(. CONTRACTOR LIC.#(REQUIRED): r-/ L) Wi P `CITY OF EVERETT BUSINESS LIC #(REQUIRED): 047140 PRIMARY CONTACT: ❑OWNER TA ONTRACTOR / OTHER(Please Specify) bAB� ZC)<S 0VP CONTACT NAME: CONTACT PHONE: 4 2s 15 --715( /!V Erti SON) CONTACT EMAIL: AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title City of Everett Official Use Only 14 Water and Sewer or such other rules and regulations now existing or which maybe established from time to FEE time.The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and Z 0 .----..._ nonpayment of charges or for any other reasonable cause.I am the owner,or I am authorized by the owner of this property to perform the work for which application is made,and I comply with the State Contractors Law 18.27 PERMIT# RCWa 296.200A WAC./4,,,A)9t1 32-43)A701 b' U ( o3 - 035 02 Owner/Authori d Agent Signature Date (Revised 10/12/2015)