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ism LAND USE PERMIT APPLICATION <br /> CITY OF EVERETT PLANNING DIVISION <br /> EVERETT INSTRUCTIONS:Complete form,sign,and date. <br /> WASHINGTON See applicable land use application packet for all required checklist items. <br /> CONTACT INFORMATION <br /> APPLICANT <br /> ADDRESS <br /> CITY STATE ZIP - <br /> PHONE EMAIL <br /> OWNER <br /> ADDRESS <br /> CITY STATE ZIP <br /> PHONE EMAIL <br /> PRIMARY CONTACT._ ]APPLICANT I OWNER I OTHER,PLEASE SPLCIFY BELOW <br /> NAME <br /> PHONE EMAIL <br /> PROJECT SITE INFORMATION <br /> ADDRESS <br /> PARCEL NO(S) <br /> PROJECT INFORMATION <br /> PROJECT NAME <br /> PROJECT <br /> DESCRIPTION .. , <br /> VALUATION I5O,DOb <br /> Authorization:I am the owner or am authorized by the owner to sign and submit this application.I certify under penalty <br /> of perjury of the laws of the State of Washington that the information on this application and all information submitted <br /> herewith is true,co etc,and correct. <br /> SIGNATURE 0416 DATE +�-{,� 2)72 <br /> PRINT NAME V <br /> CITY,STATE <br /> 2930 Wetmore Ave.St.. ,; t1. <br /> Everett,WA98201 2', 2., v, .Z <br />