3318 NASSAU ST 2018-05-30 - Laserfiche WebLink

VW TER / SEWE UTILITY PUCATI - -- CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P)425-257-8810 I FAX 425-257-8857 I (E)everetteps@everettwa.gov I www.everettwa.gov/permits PROJECT SITE INFORMATION J PROJECT ADDRESS: 3 3\ g 06.35 e-„U V. l r../t:✓si kl' c L3t4- �'l`eZf>I IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? 0 NO 0 YES, FROM TO UTILITY APPLICATION INFORMATION SEWER(check all that apply) WATER(check all that apply) SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION ❑SIDE SEWER ALTERATION 0 COMPLETE SERVICE ❑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 0 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: ❑ I 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: 120,r� ,J A60,, TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET ��. �3 t �r�s�� 51- crY E-Vee-c--//L STATE (.A.) - ZIP Mao OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: ,.SoL w -- ?cov,A.L . / CONTRACTOR ADDRESS: STREET Z4.() I, 6(.3 1(-4--- S� CnY 5 rC�-r',1�' STATE L..) c, ZIP 1.p l.O C, CONTRACTOR PHONE: p CONTRACTOR EMAIL: CONTRACTOR LIG.#(REQUIRED):S�l a l..�l -Z`[\G� CITY OF EVERETT BUSINESS LIC.#(REQUIRED): (2'31 0 se PRIMARY CONTACT: 0 OWNER ,CONTRACTOR ❑OTHER(Please Specify) CONTACT NAME: '\ Mo iris CONTACT PHONE: 2O(c, - ice,€ - 41-4(0 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 no- -xisting or which may be established from time to FEE s time.The applicant further agrees,as a conditio• .ece. ••to ::-'. -•service tha -utilities division shall have the right at any time,without notice,to shut. or rn•. e waters 'ply for re:-irs construction,and nonpayment of charges or for any other r--so..bi- , se.I a • r"'owner, . I am:uthorized by the owner of this property to perform the work for whit =p. 'a %!fm-•• . • comply ith the tate Contractors aw 8.27 PERMIT# RCW and 296.200A WAC. r 3 I IS U t, WV 3 .. 60 2— L A.....,. . ./Ailisw/AIIIIIII- Owner/Arized Agent Signatu Date (Revised 10/12/2015)