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OJETT PLIC WORKS PERMIT APPLICATION <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 1 www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: (/2 3 W <br /> IF APPLICABLE: 0 LAND USE PROJECT#(SEPA, PRE-APP,SS,ETC.) <br /> SITE WORK FOR PROJECT TYPE:❑SFR-DETACHED ❑SFR-ATTACHED ❑DUPLEX ❑MULTI-FAMILY ❑COMMERCIAL ❑INDUSTRIAL <br /> CHANGE OF USE? TIN() 0 YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? N-54 NO 0 YES,TYPE SIZE <br /> SITE WORK/ RIGHT-OF-WAY APPLICATION INFORMATION <br /> DESCRIPTION OF WORK: kV <br /> ( FCAt.�-E YeO/✓e 23 c- Ds 4o <br /> r -1-0 <br /> I uv- v-.J Q l�vCa CL✓�N C�4 C.-12.S 1 N <br /> TO Q b V.( <br /> ❑ FENCE IN ROW FT IN HEIGHT <br /> ❑DRIVEWAY APRON/CURB CUT FT WIDE <br /> ❑ASPHALT/CONCRETE PAVING SF <br /> ❑RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF <br /> ❑RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT <br /> XCLEARING/GRADING/FILL/EXCAVATE 'Z 3 CY <br /> ❑CUT/BORE IN PAVEMENT(PARALLEL) LF <br /> ❑CUT/BORE IN PAVEMENT(NON-PARALLEL) LF <br /> .,. ,'.CONTACT INFORMATION �„ <br /> OWNER NAME: 13 ��ti✓�S <br /> OWNER MAILING ADDRESS: STREET / y 2 3 Iw/ Y1,}(c, 11-e0 6/u,9 <br /> CITY (1f2/Q2-/+ STATE Utt ZIP 9 zc).3 <br /> OWNER PHONE: '2 c-- ? c ' (6 OWNER EMAIL: re-2✓P5 ? Lr�Si1 C ' <br /> APPLICANT NAME: 55171P ac l3 .-- <br /> APPLICANT MAILING ADDRESS: STREET <br /> CITY STATE ZIP <br /> APPLICANT PHONE: APPLICANT EMAIL: <br /> PRIMARY CONTACT: p OWNER 0 APPLICANT 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.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 /> f /3 2c)/( PW 1,601-1-031 <br /> O • Authorize gent Signature Date (Revised 10/12/2015) <br /> �sieet)Cd S " ' I 1 r esu 4 -/ / <br />