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elPy•/-_ <br /> PALic WORKS PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 441g1 <br /> 3200 CEDAR STREET, EVERETT,WA 98201 <br /> (P)425-257-8810 I FAX 425-257-8857 (E)everetteps@everettwa.gov I https://everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: 'j IV) <br /> SITE WORK FOR PROJECT TYPE:, SFR-DETACHED ❑SFR-ATTACHED El DUPLEX ❑MULTI-FAMILY ❑COMMERCIAL ❑INDUSTRIAL <br /> IF APPLICABLE: 0 LAND USE PROJECT#(SEPA,PRE-APP,SS, ETC.) <br /> IF APPLICABLE: 0 FRANCHISE/UTILITY COMPANY,ANNUAL BLANKET PERMIT# <br /> UTILITY COMPANY'S NAME&JOB#: JOB# <br /> DESCRIPTION OF SITE WORK/ RIGHT-OF-WAY WORK <br /> FILL IN ALL QUANTITIES OF WORK BELOW,AS APPLICABLE: <br /> ❑FENCE IN ROW FT IN HEIGHT <br /> ❑ DRIVEWAY APRON/CURB CUT FT WIDE <br /> ASPHALT/CONCRETE PAVING N SF I) <br /> o RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF q <br /> El RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT OCT 1 6 2018 <br /> ❑CLEARING/GRADING/FILL/EXCAVATE CY <br /> CITY <br /> O EVERETT <br /> ❑CUT/BORE IN PAVEMENT(PARALLEL) LF Permit Servines <br /> ❑CUT/BORE IN PAVEMENT(NON-PARALLEL) LF <br /> ❑POLE WORK/AERIAL/OVERLASH LF <br /> ADDITIONAL DESCRIPTION(AS NEEDED): <br /> Al-y+ �� w� refry rot tAP -1?-, rkv'e-u-rt,,, <br /> CONTACT INFORMATION <br /> OWNER/APPLICANT NAME: Siff 7 �/� • <br /> OWNER/APP. MAILING ADDRESS: STREET 'Z ( ZO G <br /> CITY rApfiljf STATE (/\ft- ZIP <br /> OWNER/APP. PHONE: 2 � OWNER/APP.EMAIL: <br /> CONTRACTOR NAME: 73 --T((V ]" <br /> s cel t jL1^�� <br /> CONTRACTOR ADDRESS: STREET j (4 .7 (- 0 j,'q'k <br /> CITY ,&`' (j� STATE ZIP <br /> !V <br /> CONTRACTOR PHONE: _1���� L CONTRACTOR EMAIL: Ah.--14-- Sr^ �a -�I{15 . cat-, <br /> C <br /> CONTRACTOR LICENSE#(REQUIRED) 4.� a \ EVERETT BUSINESS LICENSE#CREQUIRED): 5 2-$ q <br /> PRIMARY CONTACT: 0 OWNER /APPLICANT CONTRACTOR 0 OTHER(Architect,Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: <br /> CONTACT EMAIL: <br /> ACKNOWLEDGEMENT*I have reA wed this application and confirm the information contained herein is true and correct. Work done pursuant to this permit must <br /> comply with current federal,state,and local law. The granting of a permit only authorizes approved work and no deviations therefrom.Deviations must first be <br /> authorized in writing from the Building Official before being authorized under any circumstance.I am the owner,or I am authorized by the owner of this property to <br /> perform the work for which application is made,and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> PERMIT# <br /> (G 1b (e PW � t <br /> Owner/Authorized Agent Signature Date (Revised 1/52017) <br />