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PUBLIC WORKS PERMIT AhLICATION CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT,WA 98201 (P)425-257-8810 I FAX 425-257-8857 1 (E)everetteps@everettwa.gov I https://everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: f 7l1/ I/(J. V tr SITE WORK FOR PROJECT TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ID DUPLEX ❑MULTI-FAMILY ❑COMMERCIAL DINDUSTRIAL IF APPLICABLE: 0 LAND USE PROJECT#(SEPA,PRE-APP,SS, ETC.) IF APPLICABLE: 0 FRANCHISE/UTILITY COMPANY,ANNUAL BLANKET PERMIT# UTILITY COMPANY'S NAME&JOB#: JOB# DESCRIPTION OF SITE WORK/ RIGHT-OF-WAY WORK FILL IN ALL QUANTITIES OF WORK BELOW,AS APPLICABLE: ❑FENCE IN ROW FT IN HEIGHT ❑ DRIVEWAY APRON/CURB CUT FT WIDE ASPHALT/CONCRETE PAVING SF ❑RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF Ea RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT ❑CLEARING/GRADING/FILL/EXCAVATE CY ❑CUT/BORE IN PAVEMENT(PARALLEL) LF ❑CUT/BORE IN PAVEMENT(NON-PARALLEL) LF ❑POLE WORK/AERIAL/OVERLASH LF ADDITIONAL DESCRIPTION(AS NEEDED): CONTACT INFORMATION OWNER/APPLICANT NAME: OWNER/APP. MAILING ADDRESS: STREET CITY STATE ZIP OWNER/APP. PHONE: OWNER/APP.EMAIL: CONTRACTOR NAME: CONTRACTOR ADDRESS: STREET CITY STATE ZIP CONTRACTOR PHONE: CONTRACTOR EMAIL: CONTRACTOR LICENSE#(REQUIRED): EVERETT BUSINESS LICENSE#(,REQUIRED): PRIMARY CONTACT: 0 OWNER /APPLICANT 0 CONTRACTOR 0 OTHER(Architect, Engineer, Etc.) CONTACT NAME: CONTACT PHONE: 2a5- %7 - g V IMe /fs.* CONTACT EMAIL: f J( j 9 (r� c>0461.:(,r ACKNOWLEDGEMENT:I have reviewed this application and confirm the information contained herein is true and correct.INi&K done pursuant to this permit must 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 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 perform the work for which application is made,and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. City of Everett Official Use Only PERMIT'# /o z- 7 PW / ffHJ 3 Owner/Authorized Agent Signature Date (Revised 1/52017)