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PSLIC WORKS PERMIT APPLICATION <br /> EVERETT CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> WASHINGTON (P)425-257-8810 I FAX 425-257-8857 I (E)everetteps@everettwa.gov I www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION �I <br /> PROJECT ADDRESS: 10817 HOLLY DR <br /> IF APPLICABLE: L=J LAND USE PROJECT#(SEPA, PRE-APP, SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE: OSFR-DETACHED =SFR-ATTACHED CI DUPLEX =MULTI-FAMILY CI COMMERCIAL <br /> CHANGE OF USE? O NO = YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? O NO O YES,TYPE SIZE <br /> SITE WORK/ RIGHT-OF-WAY APPLICATION INFORMATION <br /> DESCRIPTION OF WORK: ADULT FAMILY HOME INSPECTION <br /> O FENCE IN ROW FT IN HEIGHT <br /> = DRIVEWAY APRON/CURB CUT FT WIDE <br /> =ASPHALT/CONCRETE PAVING /i Z - SF <br /> = RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF <br /> = RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT <br /> = CLEARING/GRADING/FILL/EXCAVATE CY <br /> O CUT/BORE IN PAVEMENT(PARALLEL) LF <br /> = CUT/BORE IN PAVEMENT(NON-PARALLEL) LF <br /> CONTACT INFORMATION <br /> OWNER NAME: SHIFERAW BERHANU B <br /> OWNER MAILING ADDRESS: STREET <br /> CITY STATE ZIP <br /> OWNER PHONE: 2068155022 !OWNER EMAIL: ROBEY2006@GMAIL.COM <br /> APPLICANT NAME: SHIFERAW BERHANU B <br /> APPLICANT MAILING ADDRESS: STREET <br /> CITY STATE ZIP <br /> APPLICANT PHONE: 2068155022 APPLICANT EMAIL: ROBEY2006@GMAIL.COM <br /> PRIMARY CONTACT: = OWNER = APPLICANT = OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME:SHIFERAW BERHANU B CONTACT PHONE: 2068155022 <br /> CONTACT EMAIL: ROBEY2006@GMAIL.COM <br /> ACKNOWLEDGEMENT 1 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 /> PWW2002-001 <br /> Authorized Agent/Owner Date (Revised 10/12/2015) <br />