8306 11TH DR W 2018-07-26 - Laserfiche WebLink

ATE ; / SEWER UTILITY APPLICATION Niiial 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 `< . ? `PROJECT ADDRESS: g!262 /1ilk (A) 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 ❑YES, FROM TO UTILITY APPLICATION INFORMATION SEWER(check all that apply) WATER(check all that apply) ASIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION ❑SIDE 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: - 1:1 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: ❑.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: 'I", 2", OTHER: SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. CONTACT INFORMATION OWNER NAME: TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET CITY STATE ZIP OWNER PHONE: OWNER EMAIL: M. N /, mow CONTRACTOR NAME: ri*IS �jl/�l �/Rc. CONTRACTOR ADDRESS:222_6/ STREET 9 i ' �y. 6- (A) CITY/f )Md 5 STATE (vV k ZIP C d2O CONTRACTOR PHONE: �/ CONTRACTOR EMAIL: ti040.p(_,l 06. I`O 1 CONTRACTOR LIC.NREQUIRE1i4WS WO IN CITY OF EVERETT BUSINESS LIC.#(REQUIRED) x5 2�' i nA„N PRIMARY CONTACT:❑OWNER CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: U-62 79 PYVy V CONTACT EMAIL: tietikOjk,iltp/4w t8tha� Com)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 0 time.The applicant further agrees, as a condition precedent to receiving service that the utilities division shall have it . 0 o f the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and it 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 wh':, -.•lication is made,and I comply with the State Contraa(ctors Law 18.27 PERMIT# CW and r0A A� 5F `�// U \c60 . 166 1 Oyt, orized Agent Signature Date (Revised 10/12/2015)