6103 CADY RD 2019-06-10 - Laserfiche WebLink

A / SEWER UTILITY APPLICATION CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201. (P)425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov 1 www.everettwa.gov/permits P//ROJECT SITE INFORMATION PROJECT ADDRESS: (010'3 WA,/ Y OO� IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? NO ❑YES, FROM TO 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: 0 INSTALL BACKWATER VALVE(outside the building) 0 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 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: .1? \1 i ryVANi 'tj `l im y� TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET f � ( LI"1' CINernir‘fiftSTATE u)t \ • ZIP (18106 OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: Alf P,mkii4 CONTRACTOR ADDRESS: STREET it 1 V1 1V . CITY STATE WA, • / i(!9 ° ZIP �, /!� CONTRACTOR PHONE: O1 ) CO TRACTOR EMAIL: �\ 1 1 IC 241 V 0 t'1 t CONTRACTOR LIC.#REQUIRED: 4 f I [ Pb CITY OF EVERETT BUSIN LIC.#(REQUIRED): Q 91 515-(p PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: • CONTACT PHONE: C,1-12S✓ 9 G.J-q q 1 r 5 /\,11 Y�, MA CONTACT EMIL:A , 11 1 VVift il ( '' 610 0✓L`I .e0 AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal I•de Title City of Ever�ft 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, at'n precedent to receiving service that the utilities division shall have 14/. T DD the right at anycti e,w/ft • t notice,to shut off o turn on the water supply for repairs,construction,and Oc/1�")• nonpayment f ch es or or an: other reasona le cause.I am the owner,or I am authorized by the owner of this property to pel or he wo` hich applicatio is made,and I comply with the State Contractors Law 18.27 PERMI RCW and 29U t 0... LA 1 200 WAC a. ' tib 1 /� Owner/Authoriz-o-_Agent Sig ature' Date (Revised 10/12/2015)