Laserfiche WebLink
4riE/T P( LIC WORKS PERMIT PLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> (P) 425-257-8810 j FAX 425-257-8857 1 (E) everetteps@everettwa.gov 1 www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: 5 I I -) se Cilli&u.) t,Jcte ✓eft t vc< I 2-O <br /> IF APPLICABLE: ❑ LAND USE PROJECT#(SEPA, PRE-APP, SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:❑SFR-DETACHED IESFR-ATTACHED ❑DUPLEX ❑MULTI-FAMILY ❑COMMERCIAL LI INDUSTRIAL <br /> CHANGE OF USE? NO 0 YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? 0 NO ❑YES,TYPE SIZE <br /> SITE WORK/ RIGHT-OF-WAY APPLICATION INFORMATION J'' <br /> DESCRIPTION OF WORK: ( MI:JC 1A5191-1P LJ ci '— I2-ef tgce �i-'i l l (OI)C VC-4C <br /> ❑ FENCE IN ROW FT IN HEIGHT <br /> ❑ DRIVEWAY APRON/CURB CUT FT WIDE <br /> 0 ASPHALT/CONCRETE PAVING j (J SFDI <br /> ❑ RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF L <br /> ❑ RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT R...\ 3 ?f118 <br /> ❑ CLEARING/GRADING/FILL/EXCAVATE CY CITY (; <br /> o CUT/BORE IN PAVEMENT(PARALLEL) LF Perrn <br /> o CUT/BORE IN PAVEMENT(NON-PARALLEL) LF <br /> CONTACT INFORMATION <br /> OWNER NAME: 1'LexGIA/(!er Ctl(4 re <br /> OWNER MAILING ADDRESS: STREET (I D 8 .3 5't" SC <br /> CITY pr.5()ft&+ STATE ZIP 0 4)(.7 <br /> OWNER PHONE: Lj'ZS Cr)! ? c( OWNER EMAIL: Y 1 ex(.ALU�✓ e Z 31poo e ' LI Duet• Corn <br /> APPLICANT NAME: (j ctoww e, <br /> APPLICANT MAILING ADDRESS: STREET <br /> CITY STATE ZIP <br /> APPLICANT PHONE: APPLICANT EMAIL: <br /> PRIMARY CONTACT: 0 OWNER ❑APPLICANT 0 OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: Lk'LS- co 0 L{ 34- <br /> 1 (A.-) e V f O tv r1. % CONTACT EMAIL: Liz c- oaJ ry-cc �a r <br /> ACKNOWLEDGEMENT'I have reviewed 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 RC and 296.200A WAC. <br /> City of Everett Official Use Only <br /> PERMIT# <br /> Q '310 3 / 3 PW lR a - e `' 57 <br /> Owner/Auth5 'u - <br /> ed Agent Signature Date (Revised 10/12/2015) <br />