5005 COLBY AVE 2019-08-07 - Laserfiche WebLink

"IV , 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.everettwagov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: 60 d I ' IF APPLICABLE: 0 OUTSIDE CITY LIMITS i 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY-#OF UNITS: ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? 'Xij.2 ❑YES, FROM TO UTILITY APPLICATION INFORMATION SEWER(check all that apply) WATER(checkall 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: VI 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. �p� i fnn `C, CONTACT INFORMATION OWNER NAME: AJ 11I i V V ' CO'^I at/k,e4V TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET CITY STATE ZIP OWNER PHONE: OWNER EMAIL: e CONTRACTOR NAME: P' 19 � ! D CONTRACTOR ADDRESS: STREET v ib Are/. CITY STATE WA, . ZIP o,e s CONTRACTOR PHONE: m®' CO TRACTOR EMAIL: \ A li t IC, VIGIVVVI i CONTRACTOR LIC.#(REQUIRED) �r>< 41 1 k � CITY OF EVERETT BUSIN LIC #(REQUIRED)y„„ i. 1L°ti_ PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: , CONTACT PHONE: L- °2-S-'"\'42� -I X2,1 a CiAlt6 �A\ 041,---- -ry ft CONTACT EMAIL: A /' i` [Vt�flii I ( Its Z/410 aI *WI AGREEMENT:The undersigned applicant agrees to comply with all provisions of the Everett Municipal!.de Title City of Evert 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, a cons" n precedent to receiving service that the utilities division shall have the right at any " e,w" t notice to shut off o turn on the water supply for repairs,construction,and 4bfrAl „/ nonpayment.f ch•Tr.-s or or an other reasons,le cause.I am the owner,or I am authorized by the owner of this property top- or he wo • hich applicatio is made,and I comply with the State Contractors Law 18.27 PERMIT# RCW and 29;200• WAC 01 \ L\ \ i' . )(g U lebD \ wner/Authoriz- ••gent Sig.ature Date (Revised 10/12/2015)