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OLT P LIB WORKS PERM,PERMIT !CATION CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET EVERETT, WA 98201 (P) 425-257-8810 I FAX 425-257-8857 I (E) everetteps@everettwa.gov I www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: %O D ZF l 7(.224-1d14*-W IF APPLICABLE: ❑ LAND USE PROJECT#(SEPA, PRE-APP, SS, ETC.) SITE WORK FOR PROJECT TYPE:❑SFR-DETACHED IJS/FR-ATTACHED ❑DUPLEX ❑MULTI-FAMILY ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? ❑ NO ❑YES, FROM TO NEW WATER/SEWER SERVICE NEEDED? ❑ NO Et YES,TYPE SIZE SITE WORK/ RIGHT-OF-WAY APPLICATION INFORMATION DESCRIPTION OF WORK: (V)/L %ti"i r 25 /ôI (Z) < (z) /has ❑ FENCE IN ROW FT IN HEIGHT ❑ DRIVEWAY APRON/CURB CUT FT WIDE ❑ASPHALT/CONCRETE PAVING SF /ZO tF &-ft ❑ RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF 1 ❑ RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT ❑ CLEARING/GRADING/FILL/EXCAVATE CY ❑ CUT/BORE IN PAVEMENT(PARALLEL) LF E { `� 'r �f` ii! r ❑ CUT/BORE IN PAVEMENT(NON-PARALLEL) LF V Ac AUG - 3 zum CONTACT INFORMATION Y OF EVERETT OWNER NAME: /Iii%zVV r' 1-an' � l • OWNER MAILING ADDRESS: STREET /v 3Vk (/1/,4 CITY - STATE I/V ZIP q o`�� OWNER PHONE: 2 '56 St OWNER EMAIL: J eta '.. APPLICANT NAME: APPLICANT MAILING ADDRESS: STREET CITY STATE ZIP APPLICANT PHONE: APPLICANT EMAIL: PRIMARY CONTACT: OWNER ❑APPLICANT ❑OTHER(Architect, Engineer, Etc.) CONTACT NAME:J�� IA/a ll-re.-- CONTACT PHONE: - 3/5 " 8l CONTACT EMAIL: `)G A:,Qe-- 'drk,v*4 jvc/h BLS ACKNOWLEDGEMENT:1 have reviewed this application and confirm the information contained herein is true and correct. Work done pursuant to this permit must 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 authorized in writing from the Building Official before being authorized under any circumstance.I am the owner,or 1 am authorized by the owner of this property to perform the work for which application is made,and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. City of Everett Official Use Only PERMIT# < 20, PW 09)- V` ' Owner/Authorized Agent Signature Date (Revised 10/12/2015)