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LIC WORKS PERMIT APPLICATION <br /> OIL CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT,WA 98201 <br /> (P)425-257-8810 I FAX 425-257-8857 1(E)everetteps@everettwa.gov I https:/Ieverettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: 5-9:9.2 f' ,2&,, ,r,.& . 1°,224P.7 <br /> SITE WORK FOR PROJECT TYPE: OMR-DETACHED ❑SFR-ATTACHED ❑DUPLEX ❑MULTI-FAMILY ❑COMMERCIAL ❑INDUSTRIAL <br /> IF APPLICABLE: 0 LAND USE PROJECT#(SEPA,PRE-APP,SS,ETC.) <br /> IF APPLICABLE: O 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 /> O FENCE IN ROW FT IN HEIGHT <br /> O DRIVEWAY APRON/CURB CUT FT WIDE <br /> O ASPHALT/CONCRETE PAVING SF <br /> O RETAINING WALL/ROCKERY IN RIGHT-OF-WAY ,9S 174--_„?‘" LF <br /> O RETAINING WALL/ROCKERY-OVER 4FT IN HEIGHT FT TOTAL HEIGHT <br /> O CLEARING/GRADING/FILL/EXCAVATE CY <br /> O CUT/BORE IN PAVEMENT(PARALLEL) LF <br /> O CUT/BORE IN PAVEMENT(NON-PARALLEL) LF <br /> O POLE WORK/AERIAL/OVERLASH IF <br /> ADDITIONAL DESCRIPTION(AS NEEDED): <br /> Allzw yLOCr tiidyGL 3r''` A/ <br /> CONTACT INFORMATION <br /> OWNER/APPLICANT NAME: 14"0-...0 �CJ;c1:tr0 �y <br /> OWNER I APP. MAILING ADDRESS: srneEr /IG';X :� <br /> G `7g�/ 7 ry��/ <br /> CM �-- V 7/ STATE 1/VO4' ZIP 76.266 <br /> OWNER/APP.PHONE: Q7t 452 "''7o / OWNER/APP.EMAIL: "pc-3-4z-V 0 ,2 0 7 <br /> CONTRACTOR NAME: /''IAC LAwarc/4-pm/6 I/IC <br /> CONTRACTOR ADDRESS: 7 i4o?5' STREET Pe®otbw4- c��j <br /> CITY mfr'7 c STATE meq- ZIP /O a2y <br /> CONTRACTOR PHONE: "2S.3.5-3-7i / 7:554;2_ CONTRACTOR EMAIL: 11 / Dl'C4p/R/C e/1l4C,.Cori <br /> CONTRACTOR LICENSE#(REQUIRED): EVERETT BUSINESS LICENSE#(12EQUIRED): <br /> PRIMARY CONTACT: OWNER /APPLICANT 0 CONTRACTOR 0 OTHER(Architect,Engineer,Etc.) <br /> CONTACT NAME: CONTACT PHONE: <br /> 5-4/ E CONTACT EMAIL: <br /> ACKNOWLEDGEMENT:I have reviewed this application and confine 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 t comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> PERMIT# <br /> PW /8 / 2 - © I � <br /> �•r/Authorized Agent Signature Date (Revised 1/52017) <br />