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OLT PUBLIC 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 I (E) everetteps@everettwa.gov I www.everettwa.gov/permits <br /> q,/, , <br /> PROJECT SITE INFORMATION <br /> l <br /> PROJECT ADDRESS: II Z Z - ( 1 1 ]a VAP CJ Lam/ <br /> IF APPLICABLE: ❑ LAND USE PROJECT#(SEPA, PRE-APP, SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:DSFR-DETACHED PSFR-ATTACHED ❑DUPLEX ❑MULTI-FAMILY DCOMMERCIAL 0 INDUSTRIAL <br /> CHANGE OF USE? 0 NO 0-YES, FROM TO <br /> NEW WATER I SEWER SERVICE NEEDED? 0 NO *YES,TYPE SIZE <br /> SITE WORK/ RIGHT-OF-WAY APPLICATION INFORMATION <br /> DESCRIPTION OF WORK: U �G� G'GC�'SS O'z/�O� (/t �l v` S OWL <br /> 101d"` ?lite Sev/v--e a r -ew l b GU►7- /vt I ww\ 'bed- <br /> 0 FENCE IN ROW FT IN HEIGHT <br /> 91-DRIVEWAY APRON/CURB CUT 2-0/ FT WIDE <br /> 0 ASPHALT/CONCRETE PAVING Z0640 S4 SF <br /> ❑ RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF <br /> IS RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT S�/? 7 9L F FT TOTAL HEIGHT <br /> ❑ CLEARING/GRADING/FILL/EXCAVATE /400� F,//25Oo c��CY 468AG <br /> O CUT/BORE IN PAVEMENT(PARALLEL) LF <br /> O CUT/BORE IN PAVEMENT(NON-PARALLEL) LF <br /> / <br /> CONTACT INFORMATION <br /> OWNER NAME: 6/ 1 Q c� ) /'r`V vt 1 �eV,e(Z% i✓T' <br /> OWNER MAILING ADDRESS: STREET —!y/ 74 2 h 'kM1/t-k4Na Uf�,Ivvd• ),w�C 27 ? {/�7 <br /> CITY I �7.,,PAA STATE C74— ZIP �jj,�^' <br /> OWNER PHONE: ag. OWNER EMAIL: <br /> APPLICANT NAME: ,rj r c _ L;st fS cs.:3 err 5 Sc'rz v/C 1 <br /> APPLICANT MAILING ADDRESS: STREET 2 02 / v,2z Ave <br /> CITY IVA STATE �y ZIP g.36)0,:)7 <br /> APPLICANT PHONE: Z5- 2S�— 555 APPLICANT EMAIL: oerc-Cf5tckheri...C� 42-&/' ( ink,net <br /> PRIMARY CONTACT: 0 OWNER '.APPLICANT I OTHER(Architect, Engineer, Etc.) vu2_•2. <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. 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# <br /> L: /,-0(50, PW 9-©W-0`1S <br /> Owner/Authorized Agent Sign ture C.) Date (Revised 10/12/2015) <br />