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PI�LIC WORKS PERMIT �LICATION <br />CITY OF EVERETT PERMIT SERVICES <br />3200 CEDAR STREET, EVERETT, WA 98201 <br />(P) 425-257-8810 � FAX 425-257-8857 �(E) everetteps@everettwa.gov � www.everettwa.gov/permits <br />PROJECT SITE INFORMATION <br />PROJECT ADDRESS: 3619 RUCKER AVE <br />IF APPLICABLE: O LAND USE PROJECT #(SEPA, PRE-APP, SS, ETC.) <br />SITE WORK FOR PROJECT TYPE: OSFR-DETACHED OSFR-ATTACHED ODUPLEX OMULTI-FAMILY C�COMMERCIAL <br />CHANGE OF USE? O NO 0 YES, FROM TO <br />NEW WATER / SEWER SERVICE NEEDED? Cl NO O YES, TYPE SIZE <br />DESCRIPTION OF WORK: <br />0 FENCE IN ROW <br />SITE WORK / RIGHT-OF-WAY APPLICATION INFORMATION <br />INSTALL NEW OIL WATER SEPARATOR <br />I� DRIVEWAY APRON / CURB CUT <br />FT IN HEIGHT <br />FT WIDE <br />C�ASPHALT/ CO CRE PAVING SF <br />0 RETAINING W / ROCKERY IN RIGHT-OF-WAY LF <br />O RETAINING WALL / ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT <br />O CLEARING / GRADING / FILL / EXCAVATE CY <br />O CUT/BORE IN PAVEMENT (PARALLEL) LF <br />C=1 CUT/BORE IN PAVEMENT (NON-PARALLEL) LF <br />U <br />CONTACT INFORMATION <br />OWNER NAME: EVERETT CITY OF <br />OWNER MAILING ADDRESS: srReer 3002 WETMORE AVE <br />cirv EVERETT srnre WA ziP 98201 <br />OWNER PHONE: 4252578956 OWNER EMAIL: <br />APPLICANT NAME: BURTON CONSTRUCTION INC t�l L� £nrs� : v� U 3 M� <br />APPLICANT MAILING ADDRESS: sTReer 1000 INDUSTRY DR ��/�� Ei;��;i/�-�gs (a«��. C�..�j �,�39 <br />c�Tv TUKWILA STATE WA z�P 98188 <br />APPLICANT PHONE: 4252139889 APPLICANT EMAIL: <br />PRIMARY CONTACT: � OWNER O APPLICANT �OTHER (Architect, Engineer, Etc.) L�IV'T�2.i�'Ci�"P.. <br />CONTACT NAME: DUCKETT WILLIAM CONTACT PHONE: 2064662237 <br />CONTACT EMAIL: will@burtonconstruction.net <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 loca/ /aw. 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. 1 am the owner, or I am authorized by the owner of this property to <br />perform the work for which application is made, and 1 comply with the State Contractors Law 18.27 RCW and 296.200A WAC. <br />t?/"i�/�t� �� '��� City of Everett Official Use Only <br />Authorized Agent/Owner Date <br />PERMIT # <br />PW1610-015 <br />(Revised 10/12/2015) <br />