1005 GRAND AVE 2019-01-28 - Laserfiche WebLink

WATER / SEWER UTILITY APPLICATION Fir- 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.everettwagov/permits c PROJECTSITEINFRNIATIoN t '= PROJECT ADDRESS: 1 O o� Vi5tigg( an • IF APPLICABLE: 0 OUTSIDE CITY L ITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY=#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? NO 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 SIDE SEWER INSTALLATION SERVICE/METER USE: KINSTALL 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: V l VILti YniUrATSial TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET 1\ O 0ouNttA,Ix • CITY 11Lti•e/ STATE• ZIP atl.z4 1 OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: A,( Ptimmilio CONTRACTOR ADDRESS: STREETeecreitt 111/2+011/4441414,,,, ftati. CITY STATE\AM . ZIP ot02.06 D1 a V tiitl 1® 'lCONTRACTOR PHONE: � CO TRACTOR EMAIL: i CONTRACTOR LIC #(REQUIRED) t CITY OF EVERETT BUSIN LIC #(REQUIRED) PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: e L �n �/ CONTACT PHONE: Lii* 22`�I(,�12/4119104M1 0,141(i16 1 `�A 1 CONTACT EMAIL: //i 1 pah14I l ,ti .el4/ AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal ode Title City of EveOfficial Use Onlynl , ' 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to FEE A9'� time.The applicant further agrees, a con.]'•n precedent to receiving service that the utilities division shall have 4 /)O • (,Jv the right at any ' e,w' • t notic to shut off o turn on the water supply for repairs,construction,and h nonpayment.f ch-r.-s or or an other reasona,le cause.I am the owner,or!am authorized by the owner of this property top- or he wo • hich applicatio .is made,and I comply with the StateContractorsLaw 18.27 PERMI 7 /and292OOJACJ uner/Authoriz '�` gent Sig,ature Date (Revised 10/12/2015)