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PUS.IC WORKS PERMIT AOLICATION <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 I www.everettwa.gov/permits <br /> 7 PROJECT SITE INFORMATION �y <br /> PROJECT ADDRESS: 7v2_ y LkWI eF_ <br /> IF APPLICABLE: ❑ LAND USE PROJECT#(SEPA, PRE-APP, SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:❑SFR-DETACHED ❑SFR-ATTACHED []DUPLEX ❑MULTI-FAMILY ❑COMMERCIAL ❑INDUSTRIAL <br /> CHANGE OF USE? ❑ NO ❑YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? ❑ NO ❑ YES,TYPE SIZE <br /> SITE WORK / RIGHT-OF-WAY APPLICATION INFORMATION <br /> DESCRIPTION OF WORK: Ik!j 16i i <br /> ❑ FENCE IN ROW FT IN HEIGHT <br /> D DRIVEWAY APRON/CURB CUT 2FT 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 /> ❑ 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: a rcC,'� <br /> OWNER MAILING ADDRESS: STREET pyTfvtFj- <br /> CI�TY" �; STATE ZIP <br /> OWNER PHONE: 2- 7�-7= Za 6 b OWNER EMAIL: e-4,C'rN0A, 'z <br /> APPLICANT NAME: Jct GG e, <br /> APPLICANT MAILING ADDRESS: STREET 5 <br /> CITY STATE ZIP <br /> APPLICANT PHONE: APPLICANT EMAIL: <br /> PRIMARY CONTACT: ❑ OWNER ❑APPLICANT ❑ OTHER(Architect, Engineer, Etc.) G� <br /> CONTACT NAME: CONTACT PHONE: `7� [ 'J�6 <br /> J ► ����� 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 /> PW14()� - 0ggZ <br /> Owner/Authorized 4n S nature Date (Revised 10/12/2015) <br />