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PULILIC WORKS MIT AWLICATION <br /> '11111111PoZC---A <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> (P) 425-257-8810 I FAX 425-257-8857 I (E) everetteps@everettwa.gov I www.everettwa.gov/permits <br /> If $ 4., :_: PROJECT SITE INFORMATION <br /> . ,. ... . ,.. ..�._ < ,,.1_ �,._ x, 11. ...�. . ..__ �_ � � . ., . <br /> PROJECT ADDRESS: a ' J 1---)M cUJ(_- Eve,-e- I/WA- -/D a�7 <br /> IF APPLICABLE: 0 LAND USE PROJECT#(SEPA,PRE-APP,SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:I:SFR-DETACHED ❑SFR-ATTACHED El DUPLEX El MULTI-FAMILY ❑COMMERCIAL CI INDUSTRIAL <br /> CHANGE OF USE? ❑NO ❑YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? 0 NO 0 YES,TYPE SIZE <br /> SITE WORK/ RIGHT OF-WAY;APPLICATION INFORMATION <br /> DESCRIPTION OF WORK: <br /> )FENCE IN ROW FT IN HEIGHT <br /> ❑ DRIVEWAY APRON/CURB CUT FT WIDE <br /> 0 ASPHALT/CONCRETE PAVING SF g t $`3 s e <br /> ❑ RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF <br /> 4 Li i <br /> ALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL H T JUN1 <br /> ❑ RETAINING W 4 201812...f) <br /> LI <br /> 0 CLEARING/GRADING/FILL/EXCAVATE CY <br /> CITY OF EV9 <br /> 0 CUT/BORE IN PAVEMENT(PARALLEL) LF ''.c.•ar° '✓^ xs <br /> ❑CUT/BORE IN PAVEMENT(NON-PARALLEL) LF <br /> CONTACT INFORMATION <br /> OWNER NAME: Z /.7 440.2d d u(•Leg'ot, <br /> OWNER MAILING ADDRESS: STREET 5-7/ ✓ -" q -1,-t a (e._ r1 <br /> /(l-C \ CITY STATE b.,/ l ZIP /> 20 <br /> OWNER PHONE: OWNER EMAIL: <br /> APPLICANT NAME: 25<70'1 al elt/ ��9®t <br /> APPLICANT MAILING ADDRESS:- STREET / 5-4/i' S Z7/fil `�vim— <br /> /fey---r5 1 CITY G'( <br /> STATE , /° ZIP 9V-2-0 <br /> APPLICANT PHONE 412.- (lift 5/ 14 ( APPLICANT EMAIL: Gcc 13 m_r ny <br /> U�ryof f� -cp."— <br /> PRIMARY CONTACT: OWNER 0 APPLICANT 0 OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: <br /> 5(4/VC.,e . CONTACT EMAIL: 5G(‘M---P/ <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 applic ' n 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 /> ( c6 PW (g06-- oma <br /> Owner/Authorized A ent Signature Date (Revised 10/12/2015) <br />