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NEN® PALM PV I*1- KS PEA J OT •PLIC AT ON <br /> CITY OF EVERETT PERMIT SERVICES <br /> EVE � � 3200 CEDAR STREET, EVERETT,WA 98201 <br /> WASHINGTON (P)425-257-8810 I FAX 425-257-8857 I (E) everetteps@everettwa.gov I https://everettwa.gov/permits <br /> PROJECT.SIT.E.IigFOi3M1 AT TON= _ ge!'a.< :>-_ <br /> PROJECT ADDRESS: j_622 C.1'I,,e-re\e.pc l Grace-elf) WA l 9 02201_ 'Y6Gl^{a-A-1 vt 19I k)-3IAt i . <br /> SITE WORK FOR PROJECT TYPE: ❑SFR-DETACHED ❑TOWNHOUSE 0 DUPLEX DADU LJMULTI-FAMILY ❑COMMERCIAL 0 INDUSTRIAL <br /> IF APPLICABLE: ❑ LAND USE PROJECT#(SEPA, PRE-APP, SS, ETC.) <br /> a.DESCitiiaTION<OF.:SITE li oia 1`I11G T Oi04.40"W1 RIS ` .C .,. :; <br /> FILL IN ALL QUANTITIES OF WORK BELOW,AS APPLICABLE: DRAINAGE MITIGATION QUESTIONS: <br /> ❑ FENCE IN ROW FT IN HEIGHT STORMWATER DISCHARGES TO: <br /> ❑DRIVEWAY APRON/CURB CUT FT WIDE ❑Combined Sewer <br /> ❑ASPHALT/CONCRETE PAVING SF ®Separated Storm Sewer <br /> ❑RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF ®Direct Discharge to Snohomish River or Puget Sound <br /> ❑RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT TRIGGERED REQUIREMENTS: <br /> ❑CLEARING/GRADING/FILL/EXCAVATE CY ® MR2 Only ®MR1-5 ❑MR1-9 <br /> O CUT/BORE IN PAVEMENT(PARALLEL) LF QUANTITY OF PROPOSED HARD SURFACES: <br /> ❑CUT/BORE IN PAVEMENT(NON-PARALLEL) LF Proposed Roof Area: SF <br /> ❑ POLE WORK/AERIAL/OVERLASH LF Proposed Hardscape: SF <br /> ADDITIONAL DESCRIPTION(AS NEEDED): 1 1 - Total New+Replaced: SF <br /> } UA �,D\C:�Ci -6 1 ZAAsA- ( -Nc� i'LTZ ce1cJ.f- fr- (roc)i c.-cc -„. <br /> OWNER/APPLICANT NAME: P 4,4(v) ('il i ie , L�1-c, <br /> OWNER/APP. MAILING ADDRESS: ��l(STREET q 706 ,c4 y rt`JIV r: 'fJ E i'fc- %1- Go <br /> CITY f le, STATE w n ZIP -(O_i/S— <br /> OWNER/APP. PHONE: 21ZS-7f3-SlyO OWNER/APP.EMAIL: :i ‘,roY,,)4 ":,t (/-. <br /> *Required for Work in Public Right-of-Way <br /> CONTRACTOR NAME: `+„�� • <br /> CONTRACTOR ADDRESS: STREET <br /> CITY STATE ZIP <br /> CONTRACTOR PHONE: // CONTRACTOR// EMAIL: �jj <br /> CONTRACTOR LICENSE#(REQUIRED): i.Zfi I NS / U I C(Q EVERETT BUSINESS LICENSE#(REQUIRED) Li//��1 Lk t I <br /> PRIMARY CONTACT: ❑OWNER /APPLICANT fi CONTRACTOR ❑OTHER(Architect, Engineer, Etc.) <br /> CONTACT AME: CONTACT PHONE: <br /> {iI/ 1/ CONTACT EMAIL: <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 whic. -poll •ion 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 /> 1� — O Sj2 22 - PW 22oLI 0 pal <br /> . , .. Signature Date (Revised 4/15/2019) <br /> Owner/Authori��gnatu <br /> /z_ <br />