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I <br /> OLT BLIC WORKS PERMIT XPLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT,WA 98201 <br /> (P)425-257-8810 1 FAX 425-257-8857 1 (E)everetteps@everettwa.gov 1 https://everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: RUCKER AVE & HEWITT AVE <br /> SITE WORK FOR PROJECT TYPE: ❑SFR-DETACHED ❑SFR-ATTACHED ❑DUPLEX DMULTI-FAMILY VCOMMERCIAL ❑INDUSTRIAL <br /> IF APPLICABLE: 0 LAND USE PROJECT#(SEPA, PRE-APP, SS, ETC.) <br /> IF APPLICABLE: 0 FRANCHISE/UTILITY COMPANY,ANNUAL BLANKET PERMIT# <br /> UTILITY COMPANY'S NAME&JOB#: JOB# 5164 <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 /> ❑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 /> 2 CLEARING/GRADING/FILL/EXCAVATE j Li A I Z'' 10 IG CY <br /> ❑ CUT/BORE IN PAVEMENT(PARALLEL) LF <br /> ❑ CUT/BORE IN PAVEMENT(NON-PARALLEL) LF <br /> ❑ POLE WORK/AERIAL/OVERLASH LF <br /> ADDITIONAL DESCRIPTION(AS NEEDED): <br /> ,AP, -o F t-to:A- eexiShil5 Ohl;.1"05 to 1Lt-a,in sitfilli <br /> CONTACT INFORMATION <br /> OWNER/APPLICANT NAME: JOHN GARDIN <br /> OWNER/APP. MAILING ADDRESS: STREET 43530 SE NORTH BEND WAY <br /> ciTY NORTH BEND STATE WA ZIP 98045 <br /> OWNER/APP. PHONE: 425-864-5547 OWNER/APP. EMAIL: JOHNG(c�APSLOCATES.COM <br /> CONTRACTOR NAME: APPLIED PRFOESSIONAL SERVICES <br /> CONTRACTOR ADDRESS: STREET 43530 SE NORTH BEND WAY <br /> CITY NORTH BEND STATE WA ZIP 98045 <br /> CONTRACTOR PHONE: 425-864-5547 CONTRACTOR EMAIL: JOHNG@APSLOCATES.COM <br /> CONTRACTOR LICENSE#(REQUIRED): APPLIPS981 LD EVERETT BUSINESS LICENSE#(REQUIRED): 042071 <br /> PRIMARY CONTACT: gOWNER /APPLICANT 0 CONTRACTOR 0 OTHER(Architect, Engineer, Etc.) <br /> ICONTACT NAME: CONTACT PHONE: 425_864_55q 7 <br /> JOHN GARDIN CONTACT EMAIL: JOHNG@APSLOCATES.COM <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 Officials 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 f r 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 /> ,/,',./ 4 Jam. , /ia P i ss-a4 <br /> � f <br /> Owner/Authorized Agent Signature Date (Revised 1/52017) <br />