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`���LLc'� 7`D �/�,�C� c� ��Z� �� J a /� <br />����I� WOR�� �����i� A��G�O�ATI�N <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.go <br />PFtOJECT SITE IFI��RMAiIOBd <br />PROJECT ADDRESS: O 3 � <br />IF APPLICABLE: ❑ LAND USE PROJECT #(SEPA, PRE-APP, SS, ETC.) <br />SITE WORK FOR PROJECT TYPE: �SFR-DETACHED ❑SFR-ATTACHED �PLEX ❑MULTI-FAMILY ❑CO <br />CHANGE OF USE? lXJ NO ❑ YES, FROM TO � <br />NEW WATER / SEWER SERVICE NEEDED? �O ❑ YES, TYPE <br />E <br />SITE WORK / RIGHT-OF-WAY APPLICQ►7'IOf�I INFOR TION <br />DESCRIPTION OF WORK: L�if,/�O �� �_OSS � ! �S f�' <br />❑ FENCE IN ROW <br />❑ DRIVEWAY APR� <br />❑ ASPHALT / CON� <br />❑ RETAINING WAI <br />❑ RETAINING WAI <br />❑ CLEARING / GR. <br />L1 CUTBORF IN P <br />❑ CUT/BORE IN P. <br />,, <br />�d01-hU'/�'.�ICJ i <br />�o� �a� ���y ��V� <br />�U� p�' o�f i lsCw�n��� <br />W�d-�� �� Yvur� <br />�i-�,v,��� r�a,.._�l <br />; <br />OWNER NAME: <br />OWNER MAILING ADDRESS: <br />OWNER PHONE: litJ� S <br />APPLICANT NAME: <br />APPLICANT MAILING ADDRESS: <br />APPLICANT PHONE: � <br />• <br />► ; e'�� .,� � <br />� F� <br />l%J% <br />� /� ✓ <br />�r.�s <br />cirv <br />INFORMAil�tol <br />OWNER EMAIL: <br />IAL ❑INDUSTRIAL <br />�i��lgZ� <br />�'i%�7C� G���7�E�A' <br />� ���o-/� <br />STATE <br />STATE <br />APPLICANT EMAIL: <br />0 <br />� <br />PRIMARY CONTACT: WNER ❑ APPLICANT ❑ OTHER (Architect, Engineer, Etc.) <br />CONTACT NAME: ���� // CONTACT PHONE: `�O6 '�j % O` �-� <br />/ <br />SCt /Vt ��'�� CONTACT EMAIL: � �0 <br />ACKNOWLEDGE NT: I have reviewed this applicafion and confirm the information contained herein is ue and correct. Work done pursuanf to this permit must <br />cornply with cur nt federa/, state, and /oca! law. The granting of a permit only authorizes approved work and no deviations therefrom. Deviations must first be <br />authorized i riting from the Building Official before being authorized under any circumstance. 1 am the owner, or l am authorized by the owner of this property to <br />pr.�form e w�ork for whic.h a��plic;ation is madc, �nrl l compl}� �vith ihr, Str�tc Conh��r.tnr,t l nw 9f3.7_7 RCIN and 296. �00/1 W�C. <br />City of Everett Official Use Only <br />� PERMIT # <br />�7 // 0/6 P�/ %�!� � (�J � <br />Owner/Authorized Agent Signature Date (Revised 10/92/2015) <br />