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0 <br /> SP^/---_ ,,--A PUBLIC WORKS PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> Imo i ,. 3200 CEDAR STREET, EVERETT,WA 98201 <br /> (P)425-257-8810 I FAX 425-257-8857 I (E)everetteps@everettwa.gov I https://everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: IOC,-5 -}-'.nits D r. ) E�( (e. ‘/�J 7,p 1 1 Z -D9 <br /> SITE WORK FOR PROJECT TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DUPLEX- DMULTI-FAMILY ❑COMMERCIAL DINDUSTRIAL <br /> IF APPLICABLE: ❑LAND USE PROJECT#(SEPA,PRE-APP,SS, ETC.) <br /> IF APPLICABLE: ❑FRANCHISE/UTILITY COMPANY,ANNUAL BLANKET PERMIT# <br /> UTILITY COMPANY'S NAME&JOB#: JOB# <br /> DESCRIPTION OF SITE WORK/RIGHT-OF-WAY WORK <br /> FILL IN ALL QUANTITIES OF WORK BELOW,AS APPLICABLE: <br /> ❑ FENCE IN ROW FT IN HEIGHT <br /> ❑ DRIVEWAY APRON/CURB CUT FT WIDE <br /> NI ASPHALT/CONCRETE PAVING C-vtLvca. 1,So o s< 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 /> 0 CUT/BORE IN PAVEMENT(NON-PARALLEL) LF <br /> ❑ POLE WORK/AERIAL/OVERLASH LF <br /> ADDITIONAL DESCRIPTION(AS NEEDED): i <br /> S nn o O,h� l ro v e 1 -ccan- o;yf e4: n-- t SC-' clv . SCE ►�� ) <br /> rn.\l,2 rky e-o, _6 5a e c-uv\- 1r a 0 V-:\ �'l - <br /> CONTACT INFORMATION <br /> OWNER/APPLICANT NAME: i,A ,A f PP,re �(f &( <br /> OWNER/APP. MAILING ADDRESS: sTJ�ET 0(:)3' A-1 p 9 OrCITY _\Je/ir✓.^. STATE W V 7 1 ZIP9 2D4 <br /> OWNER/APP.PHONE:(2D(,�Z?J5 51�I2. OWNER/APP.EMAIL: O c l.eAir s--rDvT YyIo,\1 , COYV\ <br /> CONTRACTOR NAME: <br /> CONTRACTOR ADDRESS: STREET <br /> CITY STATE ZIP <br /> CONTRACTOR PHONE: CONTRACTOR EMAIL: <br /> CONTRACTOR LICENSE#(REQUIRED): M EVERETT BUSINESS LICENSE#(REQUIRED): <br /> PRIMARY CONTACT: Ar OWNER /APPLICANT 0 CONTRACTOR 0 OTHER(Architect,Engineer, Etc.) <br /> CONTACT_ C NAME: ( CONTACT PHONE: (2Q(a 2_31 —,JAI rt \j2 1 <br /> A. \UfCjv f��Q eit el .€A CONTACT EMAIL: C V\ r ,rocc''�D V Cc VAC 1 1 •C O w\ <br /> ACKNOWLEDGE WENT:I have reviewed this application and confirm the information contained herein is true arid correct. Work purq ant 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.lam the owner,or lam 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 /> 10 10/25 lc PW /8io - oSi <br /> ; <br /> Owner/Auth. ed Agent Signature Date (Revised 1/52017) <br />