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3217 COLBY AVE 2018-12-21
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3217 COLBY AVE 2018-12-21
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Last modified
12/21/2018 8:07:45 AM
Creation date
12/21/2018 8:07:45 AM
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Address Document
Street Name
COLBY AVE
Street Number
3217
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'.% TE / SEWER UTIL9 APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> (P)425-257-8810 J FAX 425-257-8857 J (E) everetteps@everettwa.gov I www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: -3 2/7 eci6i , <br /> IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# <br /> BUILDING TYPE: DSFR-DETACHED ❑SFR-ATTACHED DDULEX ❑MULTI-FAMILY#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL <br /> CHANGE OF USE? D NO 0 YES, FROM TO <br /> UTILITY APPLICATION INFORMATION <br /> SEWER(check all that apply) WATER(check all that apply) <br /> SIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION <br /> D SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY <br /> D NEW SIDE SEWER INSTALLATION SERVICE/METER USE: <br /> D INSTALL BACKWATER VALVE(outside the building) 0 SFR <br /> D SIDE SEWER CAP-OFF 0 MULTI-FAMILY-#OF UNITS: <br /> D SIDE SEWER RECONNECTION 0 COMMERCIAL <br /> MULTIPLE DOMESTIC WATER SERVICES REQUEST WATER SERVICE TYPE/SIZE:(circle desired size) <br /> D I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR 0 DOMESTIC: 3/4", 1", 2", OTHER: <br /> MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP. 0 IRRIGATION: 3/4", 1", 2", OTHER: <br /> D I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER 0 FIRE: 1", 2", 4", 6", 8", OTHER: <br /> SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER 0 DOMESTIC/FIRE COMBO: 1", 2", OTHER: <br /> SINGLE OWNERSHIP.FILL OUT REVERSE SIDE OF THIS FORM, <br /> CONTACT INFORMATION <br /> OWNER NAME: Seg yri-pfdi A'1011 TENANT NAME(If Commercial): <br /> OWNER MAILING ADDRESS: STREET Sf 'l,• <br /> CITY STATE ZIP <br /> OWNER PHONE: OWNER EMAIL: <br /> F <br /> CONTRACTOR NAME: flo/-0`F <br /> CONTRACTOR ADDRESS: STREET /66 SJ /!.t&ail �J <br /> CITY7:::,L vi/j STATE IAS- ZIP Per/32.4. <br /> CONTRACTOR PHONE: ZS' 3'4 --C'7"I CONTRACTOR EMAIL: <br /> CONTRACTOR LIC.#(REQUIRED): g Oteyi e2 CITY OF EVERETT BUSINESS LIC.#(REQUIRED): a 77 Z <br /> PRIMARY CONTACT: D OWNER CONTRACTOR D OTHER(Please Specify) y <br /> CONTACT NAME: CONTACT PHONE: C, Z-5 3/6 —(.) Z- <br /> jc`kj CONTACT EMAIL: <br /> AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title City of Everett Official Use Only <br /> 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to FEE DD <br /> time.The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have ^,� <br /> the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and (r'it/110' ,,,/ <br /> nonpayment of charges or for any other reasonable cause.lam the owner,or I am authorized by the owner of this <br /> property to perform the work for which application is made,and I comply with the State Contractors Law 18.27 PERMIT# R <br /> RCWand 2 Z1C. /5----- /2 <br /> U 6 ` —O\ <br /> Own uthorized Agent Si nature Dat (Revised 10/12/201{I b) <br />
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