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• <br /> #11/ 1Z—PP PUBLIC WORKS PERMIT IktfLICATION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> (P) 425-257-8810 I FAX 425-257-8857 I (E) everetteps@everettwa.gov I www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: Z-2---22( Harr j n ✓V v &vtArAjt1 "" Y q mil'` c/ <br /> IF APPLICABLE: ❑ LAND USE PROJECT#(SEPA, PRE-APP, SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE`ilSFR-DETACHED ❑SFR-ATTACHED ❑DUPLEX DMULTI-FAMILY ❑COMMERCIAL ❑INDUSTRIAL <br /> CHANGE OF USE? ONO 0 YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? ONO ❑YES,TYPE SIZE <br /> SITE WORK/ RIGHT-OF-WAY APPLICATION INFORMATION <br /> DESCRIPTION OF WORK: <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 /> O 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: `1 Sn(i, p'v` �f <br /> _OWNER MAILING ADDRESS: STREET <br /> 2..231Gr>'r��j��Y� y�I <br /> CITY `= Va VL_ STATE I4/'V ZIP V C <br /> ` _B e.�l 1 4 < c- <br /> OWNER PHONE: y2`j c �i �5 �L� OWNER EMAIL: !Yx 5i2 �1 <br /> APPLICANT NAME: .SLY vv1C? <br /> APPLICANT MAILING ADDRESS: STREET <br /> SIT. STATE ZIP <br /> APPLICANT PHONE: APPLICANT EMAIL: <br /> PRIMARY CONTACT: DOWNER ❑APPLICANT 0 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 I 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 /> PW I7©7-Oo3 <br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015) <br />