1211 MAPLE ST 2019-06-04 - Laserfiche WebLink

WATER / SEWER UTILITY APPLICATION 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 . e 0 '40 100-, `1 •-,1:-7 1:. "g , PROJECT ADDRESS: I, 14 , 1 - a '/" IF APPLICABLE: ❑Q. TSIC7E CITY LIMITS 0 BUILDING AREA SF 0 LOTS BUILDING TYPE: ••-• ❑TOWNHOUSE= ❑DUPLEX.. DADU ❑MULTI-FAMILY'-#OF UNITS: (]COMMERCIAL OACCESSORY CHANGE OF USE? 0 NO 0 YES, FROM TO SEWER(check...all that apply) WATER(check all that apply) , SIDE SEWER REPAIR `°" p.❑NEW WATER SERVICE INSTALLATION 0 SIDE SEWER ALTERATION ❑COMPLETE SERVICE 0 METER ONLY 0 NEW SIDE SEWER INSTALLATION SERVICE/METER USE: ❑INSTALL BACKWATER VALVE(outside the building) 0 SFR o SIDE SEWER CAP-OFF ❑MULTI-FAMILY-#"OFUNITS: „ CJ SIDE._SEWER RECONNECTION 0 COMMERCIAL;, MULTIPLE DOMESTIC WATER SERVICES REQUEST , WATER SERVICE TYPE I SIZE:(provide calcs to support size choice) 0 I AM DECLINING MULTIPLE DOMESTIC WATER SERVICES FOR ❑DOMESTIC: 03/4" Or •' 02" ❑Other: MY MULTI-FAMILY DEVELOPMENT UNDER SINGLE OWNERSHIP.. 0 IRRIGATION: 03/4" 01" ❑2" ❑Other ❑I AM OPTING TO INSTALL MULTIPLE DOMESTIC WATER ❑"FIRE: 01 02" 04" 06". 08" ❑Other: SERVICES FOR MY MULTI-FAMILY DEVELOPMENT UNDER 0 DOMESTIC/FIRE COMBO: 01" 02" ❑Other: SINGLE OWNERSHIP. FILL OUT REVERSE SIDE OF THIS FORM. ❑BACKFLOW PREVENTION(Outside): ❑RPBA ❑DCDA ODCVA OWNER NAME: r),s` ` TENANT BUSINESS NAME{1f Cott merclal): OWNER-MAILING ADDRESS: STREET I(9! 92 L„ ( 'T cm � STATE ZIP c�f OWNER PHONE. II qvq4p OWNER EMAIL. � mom.-�,.� CONTRACTOR NAME.• . #`0•. : , t CONTI i Cr'Oft ADDRESS: STREETGo s # __ cm., • . 0. % 0 0:; '- STATEixyli- ZIP A sldg:' CONTRACTOR PHONE LP0( t ' lir` . .* CONTRACTOR EMAIL r CONTRACTOR LIC #(I QUtRE -D): r .I s TY OF EVERETT BUSINESS LIC REQUIRED). ( Q PRIMARY CONTACT: ❑OWNER " A CONTRACTOR ❑OTHER(Please Specify) _ CONTACT NAME: CONTACT PHONE: Li2 (p If ..[ 1 CAA � . CtirCONTACT EMAIL: -,n r l' � /� (�'/^II C) Y"cSCG _a%/// AGREEMENT:The undersigned applicant agrees to a :.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.T 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 author/• .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 PERMIT It _—�� ' if f 1 PAO (8, Owner/Authorlzed Agent St, - ,- Date (Revised 10/12/2018)