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IOBLIC WORKS PERMIT OPPLICATION <br />CITY OF EVERETT PERMIT SERVICES <br />3200 CEDAR STREET, EVERETT, WA 98201 <br />(P) 425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits <br />PROJECT SITE INFORMATION <br />PROJECT ADDRESS: 9512 EVERGREEN WAY <br />IF APPLICABLE: = LAND USE PROJECT # (SEPA, PRE-APP, SS, ETC.) <br />SITE WORK FOR PROJECT TYPE: =SFR-DETACHED =SFR-ATTACHED =DUPLEX =MULTI -FAMILY =COMMERCIAL <br />CHANGE OF USE? ONO = YES, FROM TO <br />NEW WATER / SEWER SERVICE NEEDED? = NO = YES, TYPE SIZE <br />IDESCRIPTION OF WORK: <br />= FENCE IN ROW <br />EVERETT LIBRARY - EVERGREEN BRANCH <br />= DRIVEWAY APRON / CURB CUT <br />FT IN HEIGHT <br />FT WIDE <br />=ASPHALT/ CONCRETE PAVING SF <br />= RETAINING WALL / ROCKERY IN RIGHT-OF-WAY LF <br />= RETAINING WALL / ROCKERY OVER 4FT IN HEIGHT <br />= CLEARING / GRADING / FILL / EXCAVATE <br />FT TOTAL HEIGHT <br />CY <br />= CUT/BORE IN PAVEMENT (PARALLEL) LF <br />= CUT/BORE IN PAVEMENT (NON -PARALLEL) LF <br />CONTACT INFORMATION <br />OWNER NAME: EVERETT CITY OF <br />OWNER MAILING ADDRESS: STREET <br />3002 WETMORE AVE <br />CITY <br />EVERETT STATE WA zip 98201 <br />OWNER PHONE: <br />APPLICANT NAME: DYKEMAN <br />OWNER EMAIL: <br />APPLICANT MAILING ADDRESS: STREET 1716 W MARINE VIEW DR <br />CITE <br />EVERETT STATE WA ZIP 98201 <br />APPLICANT PHONE: 4256092327 APPLICANT EMAIL: thomash@dykeman.net <br />PRIMARY CONTACT: = OWNER = APPLICANT = OTHER (Architect, Engineer, Etc.) <br />CONTACT NAME: CITY OF EVERETT <br />CONTACT PHONE: 4252578896 <br />CONTACT EMAIL: rsanchez@everettwa.gov <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 />PLZ <br />Authorized Agent/Owner <br />Date <br />City of Everett Official Use Only <br />PERMIT # <br />�C;/ PW1712-019 <br />(Revised 1011212015) <br />