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PL*LIC WORKS PERMIT A(rLICATION <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: 10521 19TH AVE SE <br />IF APPLICABLE: EA LAND USE PROJECT # (SEPA, PRE-APP, SS, ETC.) <br />SITE WORK FOR PROJECT TYPE: =SFR-DETACHED OSFR-ATTACHED =DUPLEX =MULTI -FAMILY =COMMERCIAL <br />CHANGE OF USE? 0 NO 0 YES, FROM TO <br />NEW WATER / SEWER SERVICE NEEDED? = NO 0 YES, TYPE SIZE <br />SITE WORK / 'RIGHT-OF-WAY APPLI# ON INFORMATION <br />DESCRIPTION OF WORK: PROVIDE SHELL/CORE BLDG AND SITE DESIGN <br />0 FENCE IN ROW <br />FT IN HEIGHT <br />0 DRIVEWAY APRON / CURB CUT <br />FT WIDE <br />=ASPHALT/ CONCRETE PAVING <br />SF <br />= RETAINING WALL / ROCKERY IN RIGHT-OF-WAY <br />LF <br />=1 RETAINING WALL / ROCKERY OVER 4FT IN HEIGHT <br />FT TOTAL HEIGHT <br />0 CLEARING / GRADING / FILL / EXCAVATE <br />CY <br />O CUT/BORE IN PAVEMENT (PARALLEL) <br />LF <br />O CUT/BORE IN PAVEMENT (NON -PARALLEL) <br />LF <br />OWNER NAME: SILVER PLAZA LLLP <br />OWNER MAILING ADDRESS: STREET 14304 JEFFERSON WAY <br />ER PHONE: <br />CITY LYNNWOOD STATE WA zip 98087-5906 1 <br />OWNER EMAIL: <br />APPLICANT MAILING ADDRESS: STREET <br />CITY STATE ZIP <br />(APPLICANT PHONE: 4252160318 (APPLICANT EMAIL: BRYANS@JENSENFEY.COM I <br />PRIMARY CONTACT: LI OWNER 0 APPLICANT 0 OTHER (Architect, Engineer, Etc.) <br />CONTACT NAME: [ContactName] <br />CONTACT PHONE: [ContactPhone] <br />CONTACT EMAIL: [ContactEmail] <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 />Authorized AgenVOwner Date <br />City of Everett Official Use Only <br />PERMIT # <br />PW1703-022 <br />(Revised 10/12/2015) <br />