2909 21ST ST 2018-07-26 - Laserfiche WebLink

'go- , VjU1TER / SEWER UTILITY I PLICATION `414CITY OF EVERETT PERMIT U VICES 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 1 NFORMATIPPN` PROJECT ADDRESS: (2113. . l eAre I e 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? NO 0 YES, FROM TO UTILITY APPLICATI N 1NFOItMAT[ON ` SEWER(check all that apply) WATER(check all that apply) tAt(SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION ❑SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: 0 1 NSTALL BACKWATER VALVE(outside the building) 0 SFR ❑SIDE SEWER CAP-OFF ❑ 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. El IRRIGATION: 3/4", 1", 2", OTHER: Ell 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: \)t)& 4- flh leAl tieK TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET ,j1011n % • CITY etpfrtti--- STATE W . zic14'20 OWNER PHONE: OWNER EMAIL .... .,.�. —._....,- CONTRACTOR NAME: �'�' 19 ,14/*in . CONTRACTOR ADDRESS: STREET .4 1 Y b iaW ... o. CIN eiliteref STATE Welt • /ZZIIP+ 4,o22:3 CONTRACTOR PHONE:(j42, )lill:D1�$ CO TRACTOR EMAIL:t J bl l Y/ �.1O 1tai t&t 1nl CONTRACTOR LIC.#(REQUIRED)• LIA, •k t 1 NQ CITY OF EVERETT BUSIN LIC.#(REQUIRED)/ © .1.5:5-(e., PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: . CONTACT PHONE: C,1412,S)49;5 b12 itli ai il Yvvoi1Ykil - CONTACT EMAIL:A , it I VVihY/iLIC 10 lmatitII .L-Gr'AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal i.de Title City of EveOfficial 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, a con i precedent to receiving service that the utilities division shall have the right at any " e,w' • t notice,to shut off o turn on the water supply for repairs,construction,and 4- o o nonpayment.f ch-r.-s or or an otherreasona le cause.lam the owner,or1 am authorized by the owner of this property to p. or he wo i . hich applicatio is made,and I comply with the State Contractors Law 18.27 PERMIT# RCl/Uand 29:200, WAC J U '{ 0/-0 /- /camU I Owner/Authoriz-.`�.•gent Sig,.tura Date (Revised 10/12/2015)