3324 GRAND AVE 2018-09-11 - Laserfiche WebLink

/` TE / SEWER UTILITYAPPLICATION 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: 3 2_44 44/ /d2 4fr ,2-cA. IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: F DE TACHED OSFR ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? E16 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 0 METER ONLY ❑NEW IDE SEWER INSTALLATION SERVICE/METER USE: NSTALL 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: /OGS. R-t./ 7- TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET 3 3 2% (.... 2i3"Ne) ..lye CFP( STATE LA/14 -- ZIP OWNER PHONE: Ze,a7 2 `r 7 a!g�9 OWNER EMAIL: CO _r V'e t,Va revt-FJ-2 f• e-O VIN CONTRACTOR NAME. S�W 10- -ti c-- i ti-e j CONTRACTOR ADDRESS: STREET 2 /5- /`S S`rn-t- r- CITY 5A jJ jf ; STATE 144- ZIP 5?z .. CONTRACTOR PHONE: W &7Z3 Y 9525 CONTRACTOR EMAIL: J Ip Pi ae,til €/ 97te3 , C OLi'` CONTRACTOR LIC.#(REQUIRED): S LInI -&-----0* 17 IGCITY OF EVERETT BUSINESS LIC.#(REQUIRED): PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: Jr-n Q �J� A CONTACT PHONE: 2-S- q " ,3��"V� S 5 7 v/ CONTACT EMAIL: .,}(& �p(� , eiel &ij UiJ C-GLly 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 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 4I nonpayment of charges or for any other reasonable cause.lam the owner,or I am authorized by the owner of this b property to perform the work for which application is made,and I comply with the State Contractors Law 18.27 PERMIT# RCW and 29 Vw, i5' — rci- 2ai5 U 1b05 1219 Owner/Authorized Age Signature ` Date (Revised 10/12/2015)