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PUBLIC WORKS PERMIT' APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> (P) 425-257-8810 I FAX 425-257-8857 (E) everetteps@everettwa.gov J www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: 6 ,I((_?j;� -.L C <br /> IF APPLICABLE: ❑ LAND USE PROJECT#(SEPA, PRE-APP,SS, ETC.) ��// <br /> SITE WORK FOR PROJECT TYPE:❑SFR DETACHED ❑SFR ATTACHED ❑DUPLEX 6dMULTI FAMILY ❑COMMERCIAL ❑INDUSTRIAL <br /> CHANGE OF USE? 12 NO ❑YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? ❑ NO ❑ YES,TYPE SIZE <br /> SITE WORK / RIGHT-OF-WAY APPLICATION INFORMATION <br /> DESCRIPTION OF WORK: �t IrJ z1'" 1) ?t T r'11`E(ljT� <br /> ❑ FENCE IN ROW FT IN HEIGHT <br /> ❑ DRIVEWAY APRON/CURB CUT FT WIDE <br /> ❑ASPHALT/CONCRETE PAVING 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 /> ❑ CUT/BORE IN PAVEMENT(PARALLEL) LF <br /> ❑ CUT/BORE IN PAVEMENT(NON-PARALLEL) LF <br /> CONTACT INFORMATION <br /> OWNER NAME: J If 11�%1�Dl�L,s <br /> OWNER MAILING ADDRESS: STREET U DOQ C)I DS f Iq‘c-\d <br /> CITY `f fl fe- STATE AJ A <br /> OWNER PHONE: W(t)-- ACTS' 17 3a OWNER EMAIL: -� MIT intiDIJ(1 <br /> APPLICANT NAME: (��Th t2 s -(r b U.1 '�', Ms DO S 1,L0 <br /> APPLICANT MAILING ADDRESS: STREET �O) Ij �r ��l 1t-1P <br /> CITY STATE VI <br /> APPLICANT PHONE: LI ) ..i €) APPLICANT EMAIL: (j l -1'1 , J le- 4, C.4 N'tq.LO+ , 014 <br /> PRIMARY..CONTACT: ❑ OWNER it APPLICANT. ..El OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: <br /> 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 l 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 /> l\PC) �u 4�C . S- 20 . 1 ,k PW <br /> Jivner/Aized Agent Signature Date (Revised 10/12/2015) <br />