2125 LAKE HEIGHTS DR 2019-02-06 - Laserfiche WebLink

Ojerr WAR / SEWER UTILITY AfirLICATION CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P)425-257-8810 I FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: 2!g$ /A,( e Dr sere 1D4 Ilao IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ,gSFR-DETACHED ❑SFR-ATTACHED ODULEX ❑MULTI-FAMILY-#OF UNITS: I ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? 0 NO ,ArYES, FROM &OTO Perna T{DN 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. l CONTACT INFORMATION f p OWNER NAME: , Q,y�,f QT'tine.. North e,. TENANT NAME(If Commercial): OWNER MAILING ADDRESS: LI STREET 19oa, - )26* i l 5E CITY 61)pkQr STATE WI'1 ZIP ChtegOg OWNER PHONE: q 945-33.P-4.41 OWNER EMAIL: V\4 et yti1 1tj 0,0 CONTRACTOR NAME: Nto 1'teu) 5trae t i nf1 ftA P' iO 6et E��V CONTRACTOR ADDRESS: STREET Po hit Ian L} CITY Si-iuntooDA STATE 1/L5ri ZIP itaa9aw CONTRACTOR PHONE: 49,S ' A'I$-1110 CONTRACTOR EMAIL: Y11,Vyly+p,(vCpl�4ta) ?fl1,I � ( Al CONTRACTOR LIC.#(REQUIRED): NOM-1kNI`1OOb CITY OF EVERETT BUSINESS LIC.#(REQUIRED): 06Woltp 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 he a 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 PERMIT# • ` c / U 1 I) -OL1 Owner Authorized Agent Signature Date (Revised 9/23/2016)