2432 MAPLE ST 2019-02-11 - Laserfiche WebLink

eV,- , TE I SEWER UTILITY A PPLIC TI `414 .71CITY 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 ,,P . JEC T SITE INFORMATION' Ii0 PROJECT ADDRESS: '42-A 3 Z tM ANP L- E - -t' 6,\_10" ---c-1- tn./, `6Zt:).1 IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL 0 INDUSTRIAL CHANGE OF USE? ❑NO ❑YES, FROM TO UTILITY APPLICATION INFORMATION SEWER(check all that apply) WATER(check all that apply) SIDE SE ER REPAIR 0 NEW WATER SERVICE INSTALLATION Ci SIDE S ER ALTERATION 0 COMPLETE SERVICE 0 METER ONLY NEW DE SEWER INSTALLATION SERVICE/METER USE: ❑ INSTALL BACKWATER VALVE(outside the building) ❑SFR ❑SIDE SEWER CAP-OFF ❑ 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 ❑ 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: DR.,z, 1 '' l (Jv/V/t�,QC',•1 �/� /STENNANT-NA�ME(If Commercial): OWNER MAILING ADDRESS: STREET '2-L 1 }S2 ► )(v)e E eg CITY �(/ErZ�1 STATE\N4 ziP9 OZo I OWNER PHONE: 1425'—Z.-1-414- ‘.--S i OWNER EMAIL: t('V V\JSva►N MX --IN-(w GJ►'v-\ ,•�. Nr Mw w CONTRACTOR NAME: SE I--I= CONTRACTOR ADDRESS: STREET CITY STATE CONTRACTOR PHONE: CONTRACTOR EMAIL: n CONTRACTOR LIC.#(REQUIRED): CITY OF EVERETT BUSINESS LIC.#(REQUI 'ED): PA---- PRIMARY CONTACT; 14 OWNER M ❑'CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: 42S -"i.-I LI- o i 3 t 1665 01AIv W I&V G) CONTACT EMAIL: fr oKi ScJO 1.)n') X @ ~IP 4...10() , Cep AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title City of Everett Official Use Only 14 Water and Sewer or such other rules and regulations now existing or which maybe established from time to FEE 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 3c) nonpayment of char.es or for any other reasonable cause.I am the owner,or I am authorized by the owner of this - ...___ property to perf. th- ork for whi application is made,and I comply with the State Contractors Law 18.27 PERMIT# e - 01g- Owner/Authorized Agent Signature Date (Revised 10/12/2015)