2713 WALNUT ST 2019-07-09 - Laserfiche WebLink

,---,0,. . ,, , ' WATER ISE iE ', UTILITY f PPLICATIO J — 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 PROJECT ADDRESS: 21 13 Vv Al�a . IF APPLICABLE: ❑ OUTSIDE CITY LIMITS ❑ BUILDING AREA SF ❑ LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OFUNITS: ❑COMMERCIAL DINDUSTRIAL CHANGE OF USE? hh' 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) O 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: 0 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: cV U TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET G' -�- y ga,lvS 4 S'/' i'ce--S CITY U vY ,H (e.0 STATE V irp f k Qom/d41:2 OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: Pt P,atim • CONTRACTOR ADDRESS: STREET d 1 V+h nteitre,f. 4 CITY n STATE WA • ZIP a,S2 CONTRACTOR PHONE:�.Y6 � ti/ ®'.j vy CO TRACTOR EMAIL: �` b� 1 k 1 O •I CONTRACTOR LIC.#(REQUIRED): �. CITY OF EVERETT BUSIN� LIC.#(REQUIRED): �_� _ � Lin 5155ce PRIMARY CONTACT: ❑OWNER 0 CONTRACTOR ❑ OTHER(Please Specify) CONTACT NAME: , CONTACT PHONE: L Ci�J --9(1 L1 ' / � 0 �, � ' CONTACT EMAIL: Aa ( 1�V�.k'J 6 ,.tom -,...1-7,"�fr Tall •` .014 AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal Code Title City of Everitt Official Use Only 14 Water and Sewer or such other rules and regulations now existing or which may be established from time to FEE 0° time. The applicant further agrees,as a condition precedent to receiving service that the utilities division shall have the right at anytime,without notice,to shut off or turn on the water supply for repairs,construction,and 430 fl nonpayment of charges or'(or any other reasonable cause.l am the owner,or I am authorized by the owner of this ✓✓✓ property to perfornj the work for Which application is made,and I comply with the State Contractors Law 18.27 PERMIT# RCW and 298.200A WAC ) I. v u l (6I t- CAI Owner/Authorizdti Agent Signature Date (Revised 10/12/2015)