2315 STATE ST 2018-12-26 - Laserfiche WebLink

/ WATER / SEER R UTILITY APPLICATION 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 wvvw.everettwa.gov/permits t5 ,�..�p PROJECT SITE INFORMATION PROJECT ADDRESS: 2. t S4 t e Sl IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL 0 INDUSTRIAL CHANGE OF USE? Yil\K2 ❑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 O NEW SIDE SEWER INSTALLATION SERVICE/METER USE: gINSTALL BACKWATER VALVE(outside the building) 0 SFR ❑SIDE SEWER CAP-OFF 0 MULTI-FAMILY-#OF UNITS: 0 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: R.,1 I /V d p;,AsCAUY r ► TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: 141131 P,1441A1ApJ.,...t.„ A CONTRACTOR ADDRESS: STREET 1 Y ,V at 02t(6 CITYeAto,r STATEWA, o ZIP CONTRACTOR PHONE: 01 CONTRACTOR EMAIL:v "p1 bi l 16 1 0114144e ; CONTRACTOR LIC.#REQUIRED: ) Itrb CITY OF EVERETT BUSINtS4 LIC.#(REQUIRED): 0 51 5.549 PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: . CONTACT PHONE: L42a 2'2'i,9 2,1 atA,vii6 �ViY> , CONTACT EMAIL: I) I mi �1� I�i " `irt ® 1 Y�V4I • AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal I ode Title \r City of Ever t 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, 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 ite;b O/nonpayment. char.-s or or an otherreasona le cause.lam the owner,orl am authorized by the owner of this • property top- or he wo hich applicatio is made,and I comply with the State Contractors Law 18.27 PERMIT# RCW and 29:200 Ciii U „ b& 0)(iiwner/Authoriz-1'gent Sig 1ature Date (Revised 10/12/2015)