5805 HIGHWAY PL 2019-06-04 - Laserfiche WebLink

-'i_R / SEWER UTILITY UCATI 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.everettwa.gov/permits = PROJECT'SITE INFORMATION , -4 t ti iti PROJECT ADDRESS: 5rg'O5 (,( ajj Pt IF APPLICABLE: 0 OUTSIDE CI LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? 0 NO ❑YES, FROM TO r ' UTILITY APPLICATION INFORMATION SEWER(check all that apply) WATER(check all that apply) a - ❑SIDE SEWER REPAIR NEW WATER SERVICE INSTALLATION-1P i►iderbi l r ❑SIDE SEWER ALTERATION 0 COMPLETE SERVICE METER ONLY 31 LIF ❑ NEW SIDE SEWER INSTALLATION SERVICE/METER USE: `Tir biboditYk• ❑ 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. 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 OMBO:_/� 1", 2", OTHjER: SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF k{`&�,c THIS FORM. ozik) - DCVO t2 Fh/{'litl'1"/yiZ , r , CONTACT INFORMATION OWNER N ME: 4-7'4ic1 fh G- IC If TENANT NAME(If Commercial): 3/6-e-/D /3,12--00C-'12-C°-1/ p � n OWNER MAILING ADDRESS: STREET .2 8 d I Sw G P'C ? Ii 5 1 2 7 / CITY �7 g.c- -'� STATE (�ff- ZIP qe/ e.6 OWNER PHONE: 6 - l_ - 2-Y3 '2-- OWNER EMAIL: CONTRACTOR NAME: __ CONTRACTOR ADDRESS: STILcr CITY STATE ZIP CONTRACTOR PHONE: CONTRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED) -----------._.. a .�.,, CITY OF EVERETT BUSINESS LIC.#(REQUIRED): ' — o H .w. PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: 11-5• 5`D 1-4 4(41` NA .,a- / 76z. CONTACT EMAIL: AGREEMENT:The undersigned applicantes 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 may be 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 nonpayment of charges or for any other reasonable cause.l am the owner,or 1 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 PERMIT# RCWan 6.200A wA a ,-)IA Aek ,r/J/// / u (soag-7 OwnerlAuthorizedRgent Signature Date (Revised 10/12/2015)