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PLIC WORKS PERMIT ARLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> "WA/NV/"---a <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: 1S3,6 ft1a 1 <br /> SITE WORK FOR PROJECT TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DUPLEX ❑MULTI-FAMILY ❑COMMERCIAL ID 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 300 SF <br /> ❑RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF <br /> ❑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 /> CONTACT INFORMATION <br /> OWNER/APPLICANT NAME: Sc L'.."t- r ._ <br /> OWNER/APP. MAILING ADDRESS:` / STREET t- <br /> 3 L A/��jv-o ►/, CITY r�7� STATE ZIP <br /> OWNER/APP.P[J7HONE: •//I'rVVV OWNER/APP.EMAIL: <br /> CONTRACTOR NAME: <br /> CONTRACTOR ADDRESS: STREET 6 l <br /> CITY STATE ZIP <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> CONTRACTOR LICENSE#(REQUIRED): EVERETT BUSINESS LICENSE#(REQUIRED): <br /> PRIMARY CONTACT: J WNER /APPLICANT 0 CONTRACTOR 0 OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: <br /> 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.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 /> ,-� PW (gOcl—035 <br /> Owner/ u orized Agent Signature Date (Revised 1152017) <br />