2123 LAKE HEIGHTS DR 2019-02-06 - Laserfiche WebLink

4err WAR / SEWER UTILITY Pm LICATION CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P)425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov 1 www.everettwa.gov/permits PROJECTS -" INFORMATION PROJECT ADDRESS: j I J3 hetti* pr . EJerCLt /DA `iia 08 IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: P1SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? 0 NO 1g YES, FROM 11+611- TO per)'1nl1i'c0✓l 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: ❑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: M'.(Att ittve- Noir west TENANT NAME(If Commercial): �-- OWNER MAILING ADDRESS: STREET I iba - laUfh Pa 56 CITY EVerict" STATE Pt ZIP ggaag '� OWNER PHONE: - - Lk, OWNER EMAIL: YY1H.�LIntliYtPj) / e 1dY1L r b)•QP [ ) co "� CONTRACTOR NAME: I� O Attu c145iyLt�.y LAT q-�'�� iiket T3M. L 'tOY XJ, Lti�A,V Ti yL CONTRACTOR ADDRESS: STREET P.b, ktri4. �.a I ti CITY 5t&4`1 A) D . STATE1.4)A ZIP eit CONTRACTOR PHONE: 805 '3 I8 -1705Q CONTRACTOR EMAIL: V\timeu (tV\5`1.7 qma i (•Cp►�I•I / CONTRACTOR LIC.#(REQUIRED): NDP} NG `ObD h. CITY OF EVERETT BUSINESS L C.#(REQUIRED): OVA% PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: CONTACT EMAIL: AGREEMENT.The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to time. The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have the right at any time,without notice,to shut off or turn on the water supply for repairs,construction,and nonpayment of charges or for any other reasonable cause.I am the owner,or I am authorized by the owner of this property to perform the work for which application is made,and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. City of Everett Official Use Only C3V19 S-1)/I4r CfMO15— d- D Owner/Authorized Agent Signature Date (Revised 9/23/2016)