4833 COLLEGE AVE 2018-07-24 - Laserfiche WebLink

,IIPzAkV"_ V�ER / SEWER UTILITY PLICATION P�►' CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT,WA 98201 (P)425-257-8810 I FAX 425-257-8857 1 (E) everetteps@everettwa.gov 1 www.everettwa.gov/permits 4 R � PROJECT SITE1 NFORMATION PROJECT ADDRESS: ic9 j — G'�.�/(te ,21-e IF APPLICABLE: 0 OUTSIDE CITY LIMITS 10 BUILDING AREA SF 0 LOT# BUILDING TYPE: , SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL 0 INDUSTRIAL CHANGE OF USE? RNO 0 YES, FROM TO UTILITY APPLICATION INFORMATIONF SEWER(check all that apply) (check all that apply) ❑ SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION >$IDE SEWER ALTERATION 0 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 0 COMMERCIAL MULTIPLE DOMESTIC i ' SERVICES REQUEST WATER SERVICE TYPE/SIZE: (circle desired size) ❑ I AM DECLI = c LTIPLE 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: V-01254:t 5Ctt C 1- TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET 8 3 3 cc.)I1 gip__ A.'".4.-- ( , �(� CFrY 7f�- ( (STATE ,IJV V ZIP � zt523 OWNER PHONE: 44 Z S2 �'',, 92( OWNER EMAIL aA,0s c�w►,otta) Lae CONTRACTOR NAME: 4-'i 4 p ti 1/' �' -1 EA C ? a CONTRACTOR ADDRESS: STREET 1' Wr41/1 UV Wd (11171.(47 • 4z02,--"??9 f126 CIN STATE ZIP CONTRACTOR PHONE: `2 .d6, ?62( CONTRACTOR EMAIL: �10 6 CONTRACTOR LIC,#(REQUIRED): �C Afo l)k(VC-410 Dk CITY OF EVERETT BUSINESS LIC.#(REQU RED): �,t7 `t�J ,1► PRIMARY CONTACT: OWNER ACONTRACTOR ❑OTHER(Please Specify) �` 'I CONTACT NAME: CONTACT PHONE: 2(2 , 2' 2r. / 29? 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 may be established from time to FEE OQ time. The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have �o the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and nonpayment of charges or for any other reasonable cause.l am the owner,or I am authorized by the owner of this property to perfo - the - k for which llcation is made,and I comply with the State Contractors Law 18.27 PERMIT# RCWand e*' %:9— n 0140012� Owner/Authorized Agent Signature Date (Revised 10/12/2015)