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RUBLIC WORKS PERMIT AIPLICATION <br />CITY OF EVERETT PERMIT SERVICES <br />3200 CEDAR STREET, EVERETT, WA 98201 <br />(P) 425-257-8810 1 FAX 425-267-8857 1 (E) everetteps@everettwa.gov I https:Heverettwa.gov/permits <br />PROJECT SITE INFORMATION <br />JAA N <br />PROJECT ADDRESS: t"tAe <br />SITE WORK FOR PROJECT TYPE, EISFR-DETACHED NSFR-ATTACHED []DUPLEX EIMULTI-FAMILY DCOMMERCIAL ©INDUSTRIAL <br />IF APPLICABLE: D LAND USE PROJECT# (SEPA, PRE-APP, SS, ETC. <br />IFAPPLICABLE: 171 FRANCHISEIUTILITY COMPANY, ANNUAL BLANKET PERMIT# <br />UTILITY COMPANY'S NAME & JOB #: JOB # <br />DESCRIPTION OF SITE WORK f RIGHT-OF-WAY WORK <br />FILL IN ALL QUANTITIES OF WORK BELOW, AS APPLICABLE: <br />1-1 FENCE IN ROW FT IN HEIGHT <br />0 DRIVEWAY APRON / CURB CUT FT WIDE <br />0 ASPHALT/ CONCRETE PAVING SF <br />1­1 RETAINING WALL I ROCKERY IN RIGHT-OF-WAY LF <br />0 RETAINING WALL / ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT <br />C1 CLEARING / GRADING / FILL/ EXCAVATE CY <br />1­1 CUT/BORE IN PAVEMENT (PARALLEL) LF <br />171 CUT/BORE IN PAVEMENT (NON -PARALLEL) LF <br />11 POLE WORK / AERIAL / OVERLASH LF <br />ADDITIONAL DESCRIPTION (AS NEEDED): <br />,X-11 ompon-Aack wry�- VZNfl �>,e 0V=,!:5j&e of <br />k!g ade 0��V� a tev�r <br />CONTACT INFORMATION' <br />OWNER / APPLICANT NAME:' <br />OWNER/APP. MAILING ADDRESS: STREET t2 iaw eycL4 �,g <br />crry STATE <br />OWNER I APP. PHONE: <br />JOWNER /APP. EMAIL: <br />CONTRACTOR NAME: UA <br />CONTRACTOR ADDRESS: STREET S-4t4"E;7-T3 <br />CITY <br />STATE zip <br />CONTRACTOR PHONE: <br />CONTRACTOR EMAIL: M.>, -cem. <br />CONTRACTOR LICENSE #(REQUIRED). <br />_14 <br />JEZRETT BUSINESS LICENSE #(REQUIRED): <br />PRIMARY CONTACT: WWNERIAPPLICANT Cl CONTRACTOR 91WHER (Architect, Engineer, Etc.) <br />CONTACT NAME: <br />t;fcv ��ela^ I <br />CONTACT PHONE: 15E)7121 <br />CONTACT EMAIL: 12n&_ - <br />t msn 0 Ae L f 0- <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 vRh current federal; state, and locaflaw. The granting of a panniltonly authonfzas approved vvcl( and no deviationstherafrom. Deviations must first be <br />authorized in .rating 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 16.27R901 and 296,200A WAC, <br />City olEvei-ett Official Use Only <br />PERMIT# <br />1 P -,W <br />(Revised 1152017) <br />