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'i <br /> PIJIgLIC WORKS PERMIT im LIGATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> (P)425-257-8810 ( FAX 425-257-8857 I (E) everetteps@everettwa.gov I www.everettwa.gov/permits <br /> PROJECT seek INFORMATION <br /> PROJECT ADDRESS: 5-3V (If <br /> IF APPLICABLE: 0 LAND USE PROJECT#(SEPA, PRE-APP,SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:OSFR-DETACHED ❑SFR-ATTACHED DDUPLEX El MULTI-FAMILY ❑COMMERCIAL [(INDUSTRIAL <br /> CHANGE OF USE? D NO D YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? 0 NO 0 YES,TYPE SIZE <br /> SITE WORK/ RIGHT OF-WAY`.APPGICATION INFORMATION <br /> /� 4 )4-ir <br /> DESCRIPTION OF WORK: <br /> L.774 2pk7 /(AT <br /> 0 FENCE IN ROW FT IN HEIGHT <br /> D DRIVEWAY APRON/CURB CUT FT WIDE <br /> D ASPHALT/CONCRETE PAVING SF <br /> D RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF <br /> D RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT <br /> D CLEARING/GRADING/FILL/EXCAVATE CY <br /> D CUT/BORE IN PAVEMENT(PARALLEL) LF <br /> D CUT/BORE IN PAVEMENT(NON-PARALLEL) LF <br /> CONTACT INFORMATION <br /> OWNER NAME: Id et AL J ikvy-1 ®• 4 -..2E W <br /> OWNER MAILING ADDRESS: STREET 6-3 VI' /n��Q�!��}-fie- Z <br /> CITY �� ��/f1Q/ve STATE ///1/0 ZIP JT 20 9 <br /> OWNER PHONE644.0 -as- - 6$ OWNER EMAIL <br /> APPLICANT NAME: ,S;94 47-- <br /> APPLICANT MAILING ADDRESS: STREET <br /> CITY STATE ZIP <br /> APPLICANT PHONE: APPLICANT EMAIL: <br /> ' <br /> PRIMARY CONTACT: 0 OWNER wD APPLICANT 0 OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: ' <br /> i2,L/f1wv 0 , L CONTACT EMAIL: <br /> ACKNOWLEDGEMENT.I have reviewed this application and confirm the information contained'hereinls true and correct. Work dohe'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 1 am authorized by the owner of this property to <br /> perform the work for which application is made,and 1 comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> PERMIT# <br /> PW iv:- ® i f <br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015) <br />