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PI�IC WORKS PERMIT A�LICATION <br /> CITY OF [VERETT PERMIT SERVICES / � �� `���/ <br /> 32U0 CEDAR S7RE[T, EVFRETi, VJH 9820� p� �/�O I —f/�� <br /> (P)425-257-8810 � FAX 425-257-8857 � (E) everetteps@everethva gov � v�nw�.everethva.gov/permlis <br /> PROJECT SI4E INFORMATION <br /> PROJECT ADORESS: � `� <br /> IF APPUCABLE: ❑ LAND USE PROJECT#(SEPA, PRE-APP, S5. ETC ) <br /> SITE WORK FOR PROJECT TYPE:�S�R�DETAGHE� ❑SPF-ATTACHEO ❑DUFLEX ❑tdULTI-FAMILY ❑COIdIdERCIa� ❑INDUST�'.'P� <br /> CHANGE OF USE? ❑ NO ❑ YES. FRO'�� TO __ . _ <br /> NEW WATER f SEWER SERVI�c NEEDED? ❑ hO ❑ Yf-S.TYpE S17E <br /> SITE WORK I RIGHT•OF•WAY APPLICATION INFORMATION <br /> DESCRIPTIONOFWORK � � 1 � LI/1� � �LN(J� �S �S/ <br /> U� p �iJ � u d'� Sl <br /> ❑ FENCE RJ ROW FT IN H�IGHT <br /> O URIVEWAY APRON/CURB CUT FT VJiDC <br /> ❑ ASPHALT/CONCREtE PAVRJG SF <br /> ❑ RETAINING WALL/ROCKER'(IN RIGHT-OF-WAY LF <br /> O RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOIAL H[IGHT <br /> O CLEARING I GRADING/FlLL/EXCAVATE Cv <br /> ❑ CUT;HORE IN P�VEtdENT(PARALIEL) Lf� <br /> ❑ CUT,'E30P.E IN PAVEMENT(NON-PAF2ALLEL) lF <br /> CONTACT INFORMATION <br /> i <br /> OWNER NAMG: (JLU.f I f n <br /> OWNER MAILING ADDRESS: arnrr* O �I r /4Ulc (J <br /> orv �/ {e srntF � b�L, <br /> :ir <br /> OWNER PNONE: OWNER EMAIL: <br /> APPLICANTNNME: (J �� RN(� .[���"e� <br /> APPLICANTMAIIINGADORESS: ;r�rtt � � -{y - �� <br /> i '" /JO� _ <br /> CrtV �UN 9niF �� Zi� '�i ' <br /> APPLICANT PHONE: - APPLICANT EMAIL: <br /> PRIMARY CONTACT: ❑ OWNER �APPLICANT ❑OTHEfi I�rch�tect. Engineer, Etr,) . _ <br /> CONT G NAME: CONTACT PHONE: C�" q <br /> ��N��J� CONTACT EMAIL: � aPM� �.,,�,LZ✓ �/�'j% CG�ZI <br /> lCKNOIVLEDGEMENi I have�evie�+etllhis aOP���ano�a�tlwnfimi lAe mlormafron cunlained hemm a li��e an�y co���U lM1�o�k tlonepursuanf fo Ihis permrt musf <br /> '�o.mp�y wAh cunenl lederal,slale. and local laiv T1re gran��og ol a permR onty authonres approved wortr and no Uemnhoos lherelrom Dev�atrons musf Gisf be <br /> aul^oriacd m�rnlmg Irom fhe Ou��O�ng ORraal Deloie bemg aufhon.ed under any arcomslance I am Ihe nwner, or i am auLhon.nd by Me owne�o.'this p�operty te <br /> pedorm�ne nrorklor wh�ch anP���ahnn is made,antll comply H�rth fhe Sfafe Con!racfnrs Larv t�2%RC�h'and<95 i00AWAC <br /> Crry ol Evere;f 011rnai Use Oniy <br /> PEHMII M <br /> I��{ �'6 PW l6oJ - o � o <br /> O ncrfA orizCdAgen15ignalure Date (�l^����� ��������0�5� <br />