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P LdC WORKS PERMIT A PLICATION <br />CITY OF EVERETT PERMIT SERVICES <br />3200 CEDAR STREET, EVERETT, WA 98201 <br />(P) 425-257-8810 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits <br />PRJEC'1' SITE INFORMATION _ <br />PROJECT ADDRESS: A✓e 5k <br />IF APPLICABLE: ❑ LAND USE PROJECT # (SEPA, PRE-APP, SS, ETC.) <br />SITE WORK FOR PROJECT TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DUPLEX ❑MULTI -FAMILY IXCOMMERCIAL ❑INDUSTRIAL <br />CHANGE OF USE:? NO ❑ YES, :FROM TO <br />NEW WATER / SEWER SERVICE NEEDED? ,I1 NO ❑ YES, TYPE SIZE <br />SITE W®RFC / RIG: ktT AF-WAY APPLICATION 1NF®R1M/#TION <br />OF WORK: 2 yA&W . n011f+4iG dASsroo'N lir <br />ja5Fer5. <br />❑ FENCE IN ROW <br />❑ DRIVEWAY APRON / CURB CUT <br />❑ ASPHALT / CONCRETE PAVING <br />❑ RETAINING WALL / ROCKERY IN RIGHT-OF-WAY <br />❑ RETAINING WALL / ROCKERY OVER 4FT IN HEIGHT <br />�I CLEARING I GRADING I FILL / EXCAVATE <br />❑ CUTIBORE IN PAVEMENT (PARALLEL) <br />❑ CUT/BORE IN PAVEMENT (NON -PARALLEL) <br />- 0 it ea54- <br />FT IN HEIGHT <br />FT WIDE <br />SF <br />LF <br />FT TOTAL HEIGHT <br />CY <br />LF <br />LF <br />4t <br />CONTACT INFORMATION - <br />OWNER NAME: C-ller¢ fi- AAy1<c 5C,4d015" <br />OWNER MAILING ADDRESS: STREET 3 ` co 0'a4Aa <br />CITY Fl±-e-t f'f STATE zip�c7�� C7 i <br />OWNER PHONE: <br />OWNER EMAIL: <br />APPLICANTNAME: �cc.+• an <br />APPLICANT MAILING ADDRESS: STREET1 fa W Ripe-' a ` w �r <br />L <br />CITY V✓(GAG STATE L✓A zip 7 Pa O <br />APPLICANT PHONE: APPLICANT EMAIL: <br />PRIMARY CONTACT: " ❑ OWNER W APPLICANT ❑ OTHER (Architect, Engineer, Etc.) <br />CONTACT NAME: <br />7—aG A N0.11% <br />CONTACT PHONE: Lf 9- 5 291 3 16 I <br />CONTACT EMAIL: ©( k e✓ho,n . <br />,.s rni .r.,a.,.,e ., .��nt fi., fihis narmit musf <br />ACKNOWLEDGEMENT.' 1 have reviewea mis appucanon unu uumilm U,C -.• -•• ____ .. __ _ _. _- - , <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 I comply with the State Contractors Law 18.27 RCW and 296.l wlA IcD _0::1141 <br />OwnerlAuthorized Agent Signature Date <br />PERMIT # <br />(Revised 1011212015) <br />