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PUBLIC WORKS PERMIT APPLICATION <br /> '111.11.1.sz-z".:‘ CITY OF EVERETT PERMIT SERVICES <br /> Nviiiii/W- 3200 CEDAR STREET,EVERETT,WA 98201 <br /> (P)425-257-8810 1 FAX 425-257-8857 1(E)everetteps©everettwa.gov 1 https://everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: <br /> 17....5k /J2M SI SE /d( ow f'i3200-437/5 <br /> SITE WORK FOR PROJECT TYPE: ®SFR-DETACHED -OTOWNHOUSE LEX OMUITI-FAMILY { 6MMERCIAL -BINBUST. <br /> IF APPLICABLE: 0 LAND USE PROJECT#(SEPA,PRE-APP,SS,ETC.) <br /> IF APPLICABLE: 0 FRANCHISE/UTILITY COMPANY,ANNUAL BLANKET PERMIT 1/ <br /> UTILITY COMPANY'S NAME&JOB#: JOB# <br /> DESCRIPTION OF SITE WORK I RIGHT-OF-WAY WORK <br /> FILL IN ALL QUANTITIES OF WORK BELOW,AS APPLICABLE: <br /> 0 FENCE IN ROW FT IN HEIGHT <br /> ❑DRIVEWAY APRON/CURB CUT FT WIDE <br /> ❑ASPHALT/CONCRETE PAVING SF <br /> D RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF <br /> ❑RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT <br /> ❑CLEARING I GRADING/FILL!EXCAVATE CY <br /> ❑CUT/BORE IN PAVEMENT(PARALLEL) LF <br /> ❑CUT/BORE IN PAVEMENT(NON-PARALLEL) LF <br /> 0 POLE WORK l AERIAL/OVERLASH LF <br /> ADDITIONAL DESCRIPTION(AS NEEDED): <br /> cdp seer as por/i re tiGi a,e%te-tL <br /> CONTACT INFORMATION <br /> OWNER l APPLICANT NAME: /NW Si?D`6.11/ Sh ed. <br /> OWNER/APP. MAILING ADDRESS: STREET /�1� q27 ,dial IT Ste Ido <br /> cnv (�GJ,yJ4M/0043/ STATE W� z1P��37 <br /> OWNER/APP.PHONE:Cfj 922-26t1C OWNER/APP.EMAIL: Clj/f/S& `j 14 S 0.401 ! <br /> CONTRACTOR NAME: SW?"I, 4.s' cow/nee' <br /> CONTRACTOR ADDRESS: STREET r' <br /> CITY '.—r'-"' STATE - ZIP .-..---.. <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> CONTRACTOR LICENSE#(REQUIRED):IbtairP#9207 EVERETT BUSINESS LICENSE#(REQUIRED): 507 3 y <br /> PRIMARY CONTACT: 'OWNER tAPPLICANT El-CONTR4CTOR -9TIIEf-(Architect,Engineer,Etc.) <br /> CONTACT NAME: CONTACT PHONE: (4.Z,Lj) 722, —X66 <br /> C,/9✓(.54,2/ /. v#, CONTACT EMAIL: CA iii a h hsc, ese9 <br /> ACKNOWLEDGEMENT:I have reviewed this application and confirm the information contained herein is true and correct. Work done pdrsuunt 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 lam 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 /> ERMIT# <br /> i 1 //,7 . f A, V1OLS (9O <br /> Owner/Authorized Agen'nature Date (Revised 1/x/2017) <br />