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IBLIC WORKS PERMIT SPLICATION <br /> 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://everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: I -7 [ �� I r. iJ k $ t ✓ c �- I . O 1 <br /> SITE WORK FOR PROJECT TYPE: 8SFR-DETACHED ❑SFR-ATTACHED ❑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 /> ❑FENCEFE/ IN ROW FT IN HEIGHT <br /> LdDRIVEWAY APRON/CURB CUT 9 (, FT WIDE <br /> ❑ASPHALT/CONCRETE PAVING ? Co SF <br /> ❑RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF <br /> 0 RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT <br /> ❑CLEARING/GRADING/FILL/EXCAVATE CY <br /> ❑CUT/BORE IN PAVEMENT(PARALLEL) LF <br /> ❑CUT/BORE IN PAVEMENT(NON-PARALLEL) LF <br /> ❑POLE WORK/AERIAL/OVERLASH LF <br /> ADDITIONAL DESCRIPTION(AS NEEDED): <br /> fiNI`GW 6(t(t tv-6 C144GW,ti -(-v t )z I r1 u-6- <br /> CONTACT <br /> 6CONTACT INFORMATION <br /> OWNER/APPLICANT NAME: G-c ,. ��m -e 16, J <br /> OWNER/APP. MAILING <br /> ADDRESS: STREET 1-7 3 1 � c� 1 5 <br /> CITY STATE ZIP L (12,)...0) <br /> OWNER/APP.PHONE: 14-2.S—Z 3 q i(7 it 3 OWNER/APP.EMAIL: b i c / - e 1Jw r>ea• C..- a <br /> CONTRACTOR NAME: et'ane•t. / / o " "6 c vK r t n� <br /> CONTRACTOR ADDRESS: STREET 0-C-7I (j , tK ►v(; T I o. �,• r, q <br /> CITY �l j (0... /�7, l rSTATE �'V' ZIP ! .2,7 r <br /> CONTRACTOR PHONE: ,�j ` 1.CONTRACTOR EMAIL: / <br /> CONTRACTOR LICENSE#(REQUIRED): I" ,,r U V L\M C a 7 5 i i N EVERETT BUSINESS LICENSE#(_REQUIRED):5 203 <br /> PRIMARY CONTACT: 0 OWNER /APPLICANT 9 I.ONTRACTOR 0 OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: Li-25 - 7 6' <br /> t° p /G / I CONTACT EMAIL: <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.lam 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 /> PW B(1— 0-4 1 <br /> 0 ne'[•uthorized •sent Signature Date (Revised 1/52017) <br />