5109 CHINOOK DR 2018-12-21 - Laserfiche WebLink

W "ER / SEWER UTILITY •PLICATION ,41/0 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 ' = �PROJECTrS1TEINFO MATIONS . �;, ._._, ryZ.. PROJECT ADDRESS: S/ C/'I/A)OQk IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# p� BUILDING TYPE: $.FR-DETACHED ❑SFRATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL 0 INDUSTRIAL CHANGE OF USE? ) LO ❑YES, FROM TO G.v ..,..... UT...ILT_Y AP. ..LATION I,N,.,•FOMATIO._.N.,.. zE iinf E SEWER(check all that apply) WATER(check all that apply) ❑SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION ❑SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLL /41 0 NEW SIDE SEWER INSTALLATION SERVICE/METER USE: ILL�� c' 14/ � ❑ INSTALL BACKWATER VALVE(outside the building) )81.$FR ❑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) ❑ IAM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR DOMESTIC: 3/4", 1", 2", OTHER: MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. 0 IRRIGATION: 3/4", 1", 2", OTHER: ❑1I 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. • O ,. Act INFORMATION,. , OWNER NAME: teO 9 C✓S I ► C 4J 7 TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET r° C), e®l /2 2/ ....,F��,w�.�.w...�...M,.....�.. xy..w7. ....,.�M.. CITY ,....�,STATEM...,w.. w MZIP m.w998..2 70 OWNER PHONE: L0.1..r 7 6-6S OWNER EMAIL: /A m.0 C M ww. CONTRACTOR NAME: IU 5P/1...6 CJ.9715141_C-0A-47---- //V C CONTRACTOR ADDRESS: STREET PL. A o /A4' dig V/y L. t_ CITY STATE (/C/ ZIP 2&2 7n CONTRACTOR PHONE: �"�) c? 6 -(9517 CONTRACTOR EMAIL: CONTRACTOR LIG#(REQUIRED): gt. '�j CC Q s C Cy CITY eOF EVERETT BUSINESS LIC.#(REQUIRED):.3—333(, a R PRIMARY CONTACT: ❑OWNER It ,ONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: pfu CONTACT PHONE: it e 6 _5`S`/ L)f//R6 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 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 nonpayment of charges or for any other reasonable cause.I am the owner,or!am authorized by the owner of this property to perform the work for which application is made,and I comply with the State Contractors Law 18.27 PERMIT# RCW and78¢.200A WAC. c� U i'712:7031 Owner/Authorized Agent Signature Date (Revised 10/12/2015)