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PI�..IC WORKS PERMIT A�'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 />PROJECTADDRESS: �) � � �e lau�a�e Av� �� �1 �2�3 <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? �1 NO ❑ YES, FROM TO <br />NEW WATER / SEWER SERVICE NEEDED? � NO ❑ YES, TYPE SIZE <br />SCRIPTION OF WORK: <br />/ <br />ne� $� .� <br />❑ FENCE IN ROW <br />SITE WORK / RIGHT-OF-WAY APPLICATION INFORMATION <br />o' d�� <br />, <br />r� �i,� � � I'x 10' d�� �e�a <br />❑ DRIVEWAY APRON / CURB CUT <br />J� ASPHALT / CONCRETE PAVING ��O �i 0 <br />❑ RETAINING WALL / ROCKERY IN RIGHT-OF-WAY <br />❑ RETAINING WALL / ROCKERY OVER 4FT IN HEIGHT _ <br />❑ CLEARING / GRADING / FILL / EXCAVATE <br />❑ CUT/BORE IN PAVEMENT (PARALLEL) <br />❑ CUT/BORE IN PAVEMENT (NON-PARALLEL) <br />FT IN HEIGHT <br />FT WIDE <br />SF <br />LF <br />FT TOTAL HEI <br />CY <br />LF <br />LF <br />an c� r <br />� ru� ^l7P����, �. <br />� �] U �.i �..� -�; <br />1 <br />iiC'i, `�� ;� i_:.�� <br />CITY C)1= E'JEl=�E-�T <br />Permifi �t�r����r,�=�s <br />CONTACT INFORMATION <br />OWNER NAME: il'2�'1'r an�eru�� I�- <br />OWNER MAILING ADDRESS: srREEr � �"Z e a('Q R✓L <br />��TY c J�r ��r sTATE w a Z�P 4 <br />OWNER PHONE: Q�p `�J B�o OWNER EMAIL: r y�i'. � �! J a�Nl •+ J �• Cp <br />APPLICANT NAME: MQ <br />APPLICANT MAILING ADDRESS: srReeT <br />CITY STATE ZIP <br />APPLICANT PHONE: APPLICANT EMAIL: <br />PRIMARY CONTACT: j� OWNER ❑ APPLICANT ❑ OTHER (Architect, Engineer, Etc.) <br />CONTACT NAME: CONTACT PHONE: Z,� 6`7 � Q� g$(pg <br />�d'e✓1� V�N�C�'uil �r CONTACTEMAIL: b/'�v�i'. JanG��/'u9i � M• �� • C O✓1►� <br />ACKNOWLEDGEMENT: I have reviewed thfs application and contirm the information contamecl nerem is true ancr correct. worK aone pursuant to trns 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. 1 am the owner, or 1 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 />City of Everett Official Use Only <br />PERMIT # <br />iZZ�is" PW�srz-�3� <br />Owner/Authorized Agent Signature Date (Revised 10/12/2015) <br />