9931 19TH AVE SE 2019-09-18 - Laserfiche WebLink

PUBLIC WORKS PERMIT APPLICATION CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT,WA 98201 (P)425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I https://everettwa.gov/permits PROJECT SITE INFORMATION / PROJECT ADDRESS: 4161 J ' 14 - 4.,/v-6 / •h u (..e l f W� O e, SITE WORK FOR PROJECT TYPE: DSFR-DETACHED ❑SFR-ATTACHED ❑DUPLEX DMULTI-FAMILY XCOMMERCIAL ❑INDUSTRIAL IF APPLICABLE: ❑ LAND USE PROJECT#(SEPA, PRE-APP,SS, ETC.) IF APPLICABLE: 0 FRANCHISE/UTILITY COMPANY,ANNUAL BLANKET PERMIT# UTILITY COMPANY'S NAME&JOB#: JOB# DESCRIPTION OF SITE WORK / RIGHT-OF-WAY WORK FILL IN ALL QUANTITIES OF WORK BELOW,AS APPLICABLE: ❑ FENCE IN ROW FT IN HEIGHT ❑ DRIVEWAY APRON/CURB CUT FT WIDE ❑ASPHALT/CONCRETE PAVING SF ❑ RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF ❑ RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT ❑CLEARING/GRADING/FILL/EXCAVATE CY ❑CUT/BORE IN PAVEMENT(PARALLEL) LF ❑CUT/BORE IN PAVEMENT(NON-PARALLEL) LF 0 POLE WORK/AERIAL/OVERLASH LF ADDITIONAL DESCRIPTION(AS NEEDED): s I +- 4 r-0-- $-(-vie .rav-d--(11 t'-1-- vt; (A) AOA \mow, c1 t yneil I1 CONTACT Aot!'INFORMATION .QWN€R/APPLICANT NAME: M I C�pk L f ��l��' -+-ke1 O4114F- /APP. MAILING ADDRESS: STREET 6)4 C) `17 j -11. . Ue, krvfe=4- f CITY i•-'044/V}1A-6S-etSTATE W ZI11970 7 AWN-ER/APP. PHONE: ' 1--S----1--S----&I-G.-2.4-25- 6 OWNER/APP. EMAIL: fr'1 Lixjk,^4- i ) _" /VV►G'�/• (V) . ,1, CONTRACTOR NAME: G.e 14-A1A- Gott -1-1- t'Gfl Oki CONTRACTOR ADDRESS: STREET CITY STATE ZIP CONTRACTOR PHONE: CONTRACTOR EMAIL: CONTRACTOR LICENSE#(REQUIRED): EVERETT BUSINESS LICENSE#(REQUIRED): PRIMARY CONTACT: QWtdER /APPLICANT 0 CONTRACTOR 0 OTHER(Architect, Engineer, Etc.) CONTACT NAME: I CONTACT PHONE: `I ZS e 'q� /-' _ 21c' Uva lCir,-c> e I Vc4v-k kz C CONTACT EMAIL: lM`Delo---- i,tXJ 1 l"�. �"(iv‘`xil hG,. C.-OVvt ACKNOWLEDGEMENT I have reviewed this application and confirm the information contained herein is true and correct. Work done pursuant to this permit must 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 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 perform t rk for which application is made, and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. City of Everett Official Use Only IF , A PERMIT# clluteI-2S - 20(0 PW1 eq`OLI (0 er/Authorized Agent Signature Date (Revised 1/52017)