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PU " IC WORKS PERMIT AP U CATI N <br /> itot.,itiaCITY 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 /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: ;2-6p0,2 C L{ c.a „ S I <br /> IF APPLICABLE: ❑ LAND USE PROJECT#(SEPA, PRE-APP, SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:❑SFR-DETACHED OFR-ATTACHED ❑DUPLEX ❑MULTI-FAMILY ❑COMMERCIAL ❑INDUSTRIAL <br /> CHANGE OF USE? -t NO ❑YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? 21 NO 0 YES,TYPE SIZE <br /> SITE WORK/ RIGHT-OF-WAY APPLICATION INFORMATION <br /> DESCRIPTION OF WORK: n <br /> 1r�� (A <br /> p(4,62� Col* J PP- <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 /> ❑ CLEARING/GRADING/FILL/EXCAVATE CY <br /> ❑ CUT/BORE IN PAVEMENT(PARALLEL) LF <br /> ❑ CUT/BORE IN PAVEMENT(NON-PARALLEL) LF <br /> � CONTACT INFORMATION <br /> OWNER NAME: 3r D ,n , ..14,(_.}4-A <br /> _ <br /> OWNER MAILING ADDRESS: STREET 143 ?- 9I St- a� toe <br /> CITY tE..4 �`��-(AA> STATE G(_0( ZIP !7 V <br /> OWNER PHONE: 'S--- -1 Sz( V` e 0— OWNER EMAIL CO STC) Y)-C-SI YI 4,e(O ©(O5fr- &-)e-T. <br /> APPLICANT NAME: 136(". 6AA A <br /> APPLICANT MAILING ADDRESS: STREET <br /> CITY STATE ZIP <br /> APPLICANT PHONE: APPLICANT EMAIL: <br /> PRIMARY CONTACT:DOWNER ❑APPLICANT ❑ OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: e-p_s- ^75-zi q4, I <br /> -46-ei. SM'itk CONTACT Ell/lAIL:CuSTO 14.L_laecvi- kA C26, ecipti(-407 to el-- <br /> ACKNOWLEDGEMENT:I have reviewed this application and confirm the information contained herein is true and corre t. 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 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-'------------74.1b /# r <br /> Owner Agent Signature Date (Revised 10/12/2015) <br />