1710 35TH ST 2018-12-27 - Laserfiche WebLink

ATE ! SEWER 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 ( www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: 11 Lt 4)5414 . 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? Iti ❑YES, FROM TO UTILITY APPLICATION INFORMATION SEWER(check all that apply) WATER(check all that apply) 0 SIDE SEWER REPAIR ❑ NEW WATER SERVICE INSTALLATION ❑ SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY O NEW SIDE SEWER INSTALLATION SERVICE/METER USE: lit INSTALL 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. tt• CONTACT INFORMATION OWNER NAME: o(A Y "c 1 LI 1(1.4 TENANT NAME(If Commercial): OWNER MAILING A DRESS: STREET CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: ! ` •'/t.i th, CONTRACTOR ADDRESS: STREETevaef tri, v d t/tritivy,t, erro. CITY STATEWA, ZIP 62116 ®o ff, a-��\t ui ti l 1c "lR CONTRACTOR PHONE: CONTRACTOR EMAIL: V i cowt CONTRACTOR LIC.#(REQUIRED): LA , s P CITY OF EVERETT BUSINESS LIC #(REQUIRED): o 5�5. tiG�- PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: • �° CONTACT PHONE: L� J of Zb-(192i ` ,Y' 6 �Al 1CONTACT EMAIL: A I VI/Ix14Iry I IC 2410 a w„i • AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Piode Title 0.. City of Evert Official Use Only 14 Water and.Sewer or such other rules and regulations now existing or which maybe established from time to FEE EVtime. The applicant further agrees, a con.u''n precedent to receiving service that the utilities division shall have /f p� the right at any ' e,w" • t notice,to shut off o turn on the water supply for repairs,construction,and h/ ), nonpayment.f ch-r.-s or or an other reasons le cause.I am the owner,or l am authorized by the owner of this `-� property top- or he wohich applicatio is made,and I comply with the State Contractors Law 18.27 PERMIT# RCW and 29:200 C $ ' U 1 166(1/-Ct. l i Owner/Authoriz-:t'gent Sig'ature Date (Revised 10/12/2015)fVl o