917 WALL ST 2019-05-22 - Laserfiche WebLink

WATER I SEWER UTILITY APPLICATION Fr4s*k/s;----A ' ‘41CITY 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 PROJECT SITE INFORMATION PROJECT ADDRESS: 1 f j1J t t 5 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? YE 0 YES, FROM TO UTILITY APPLICATION INFORMATION SEWER(check all that apply) WATER(check all that apply) 'IkSIDE SEWER REPAIR 0 NEW WATER SERVICE INSTALLATION ❑SIDE SEWER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: O INSTALL 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: S+Cip'41/1 t i4+fvi TENANT� NAME If Commercial): OWNER MAILING ADDRESS: STREET '10B SIAM I f* 1rv0°7 GJO CITY MiliihA4Vi 141 STATE WA/' ZIPqg? OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: 14161'61' b CONTRACTOR ADDRESS: STREETeNtra 1 jgreelo CITY STATE WA, . ZIP o,' CONTRACTOR PHONE:(J421)AIO12 CONTRACTOR EMAIL:blio,. Vitt IIIKA l le, 2,41 RIM `f CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSIN LIC.#(REQUIRED): PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 0 OTHER(Please Specify) 'IZb '1921 CONTACT NAME: . CONTACT PHONE: LL� ` �p� (Alio 6 � ,1 f CONTACT EMAIL: ` (/t/1 I Vl�i,14 I ,C ammiteew AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Lode Title City of Ever4t 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 coni'•n precedent to receiving service that the utilities division shall have o.....)the right at any e,w' t notic',to shut off o,turn on the water supply for repairs,construction,and RCW and n •9;200� WAC � other reasona��le cause.I am the owner,or I am authorized by the owner of this property to p-> or rhe wo loran hich applicatio is made,and I comply with the State Contractors Law 18.27 •` 1 RMIT# 1' nonpayment / � . ` \ I 0 � `ZOIC ` tgD -Oi.1 Owngent Sig"ature Date (Revised 10/12/2015)