3522 LOMBARD AVE 2019-06-04 - Laserfiche WebLink

AtL / SEWER UTILITY LIGATION 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.govlpermits { = PR0.11aC7' SITE INFORMATION- PROJECT ADDRESS: (J 52-Z, L-6/".5,4426 A-4 IF APPLICABLE: 0 OUTSIDE CITY LIMITS ❑ BUILDING AREA IPZ SF 0 LOT# 21 5 2 2 BUILDING TYPE: SFR- ETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? u NO 0 YES, FROM TO UTILITY APPLICATION INFORMATION SEWER(check all that apply) WATER(check all that apply) ❑ SID WER 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: /"l‘ie-E /�go2K.D TENANT NAME(If Commercial): 3�ZZ 1 b/K3,4Rn �dvh3 OWNER MAILING ADDRESS: STREET 3 1w, // 2°I! CITY •1=yG2g'� STATE ZIP 49 OWNER PHONE: 63 5`77 LfZ 83 OWNER EMAIL: .e.-- P.z/e. `Il$ e °" 1- 0". CONTRACTOR NAME: OGt-A)0. CONTRACTOR ADDRESS: STREET CITY STATE ZIP CONTRACTOR PHONE: CONTRACTOR EMAIL: CONTRACTOR LIC.#(REQUIRED CITY OF EVERETT BUSINESS LIC.#(REQUIRED): PRIMARY CONTACT: OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: CONTACT PHONE: 9-0 33 5 7 7 ill 8 3 M f P6 2Zb CONTACT EMAIL: 5P,,cba. y/9-. /47.4-t ce,M 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 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 �O.D O nonpayment of charges or for any other reasonable cause.I am the owner,ori am authorized by the owner of this property to perform the work for which application is made,and!comply with the State Contractors Law 18.27 I PERMIT# RCW an i,/ " _L U ( coo Owner/Authorized Agent Signature Date (Revised 10112/2015)