1514 50TH ST SE 2019-08-13 - Laserfiche WebLink

/111111/-7A ' WATER / SEWER UTILITY APPLICATION '41CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P)425-257-8810 I FAX 425-257-8857 I (E) everetteps@everettwagov I www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: 15 14 5 Oet _67:' S ` IF APPLICABLE: 0 OUTSIDE CITY LIMITS 0 BUILDING AREA SF 0 LOT# BUILDING TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DULEX ❑MULTI-FAMILY4OF UNITS: ❑COMMERCIAL CI INDUSTRIAL CHANGE OF USE? LNO ❑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: INSTALL BACKWATER VALVE(outside the building) 0 SFR 0 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: P,ISCjQ�' \ ' 7C/v ' TENANT NAME(If Commercial): OWNER MAILING ADDRESS: STREET CITY STATE ZIP OWNER PHONE: OWNER EMAIL: CONTRACTOR NAME: A-P' 19 v i� CONTRACTOR ADDRESS: STREET (DiI V$12.1101.4444,-,ef1. Vire/• CITY eAltreii 1 STATE WA e P� /ZZIIP el o &C ? 046‘2„ ..) ;' CONTRACTOR PHONE: - 01 CO TRACTOR EMAIL: 1 til I 2111 tT '1&CA tl t CONTRACTOR LIC.#(REQUIRED): t CITY OF EVERETT BUSIN LIC #(REQUIRED) 0 1 5-(eR:.,, ,. PRIMARY CONTACT: 0 OWNER 0 CONTRACTOR 0 OTHER(Please Specify) CONTACT NAME: . CONTACT PHONE: L 1 9.2,b 192d1 a 00'11L �iY� CONTACT EMAIL: A ' i) I V ii&P I C " `�o 1 .e. AGREEMENT..The undersigned applicant agrees to comply with all provisions of the Everett Municipal I ode 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 d� time. The applicant further agrees, a con.i'• 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 , nonpayment•f ch:r.-s or or an other reasona i,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# I RCW and 29.200 WACii ' q I „ J y 9(() c Oc _ I ,/IX/I/1 II YI'J1 caner/Authoriz-.' 'gent.Sig,ature Date (Revised 90/92/2095)