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P��----- ,j C WORKS , ERM T i PUOCCKNO 1
<br /> 444"-400,—; CITY OF EVERETT PERMIT SERVICES
<br /> -,44‘0_,A,.. , r
<br /> 3200 CEDAR STREET, EVERETT, WA 98201
<br /> (P) 425-257-8810 1 FAX 425-257-8857 I (E) everetteps@everettwa.gov I www.everettwa.gov/permits
<br /> PROJECT SITE INFORMATI:•N
<br /> LP�3 //,'g,k.,* 67-67c20/PROJECT ADDRESS: � s3(.....,? /CL 4 e. ��r��"c° l� �i.
<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? 0 NO 0 YES,TYPE SIZE
<br /> SITE WORK/ IGI-IT-OF-WAY/AAPPLICAT>ION INFORMATION J
<br /> DESCRIPTION OF WORK: i,/ )14)/ c�l�e/,c). rile— C� -[r CJ / /44 �O eirn,✓! f 611,1,1 . -d`
<br /> Pia V i;041 17111 e)111___6eye/00 /0um . 4/7E A id ,hariP,' tidtd'er A,,im abet
<br /> e .:idz°vt)cpl to ler/vl,0 c l- ,,-at la ze reP 40 c_siceoet cut
<br /> ❑ FENCE IN ROW FT IN HEIGHT
<br /> ❑ DRIVEWAY APRON/CURB CUT FT 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 /> 1 ❑ CUT/BORE IN PAVEMENT(NON-PARALLEL) LF
<br /> CONTACT INFORMATION
<br /> •• �
<br /> OWNER NAME: kick ! J 4 /e d
<br /> z--/l./il i�
<br /> OWNER MAILING ADDRES : STREET )/ '3_2 Y�Vg r�iilq '(07,64e0 / +/�
<br /> CITY /d/erre � STATE Zi ZIP /7J;?O(
<br /> (OWNER PHONE �� M' _jGCr L/ OWNER EMAIL: C? C� G a dam dI
<br /> gh0 - 61)/4
<br /> APPLICANT NAME: /'/j/ Age,y063,11- 5- ic s . ,41
<br /> APPLICANT MAILING ADDRESS: STREET /0.a..?/ 14 ,('e // i ,L 3
<br /> CITY i.eh.7 ,-, D/2 STATE GL/ / ZIP 9S(/fr'�V�
<br /> APPLICANT PHONE :7'%Z ,ef-/J.7 . APPLICANT EMAIL: ,"/ppjle2 r... Q O..i Cern
<br /> PRIMARY CONTACT: 0 OWNER frAPPLICANT 0 OTHER(Architect, Engineer, Etc.)
<br /> CONTACT NA E: CONTACT PHONE: .3627 9 7
<br /> U/ 1 / GL CONTACT EMAIL: ke6.6`,/ _ - yt4,r,1 ye/a/45 .�jj1'/
<br /> ACKNOWLEDGEMENT:I have reviewed this application and confirm the information contained herein is true and correctk cldne 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 1 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 /> , . .tr 1- ---/‘ PV I�tl4 1612- 032
<br /> -.---� om C
<br /> Own•r/Authorized Agent Signature Date (Revised 10/12/2015)
<br /> 1/1/101'),-Nie 20 Si-at---1- da-1ire
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