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P!-!-BLIC WORKS PERMIT f DPLICATION CITY OF EVERETT PERMIT =rtVICES t Orm- 3200 CEDAR STREET, EVERETT, WA 98201 (P) 425-257-8810 I FAX 425-257-8857 I (E) everetteps@everettwa.gov I www.everettwa.gov/permits u 1 cPROJECT SITE INFORMATION �( PROJECT ADDRESS: 1;Vet/ �U 51 S C Eve ye+-1- °V A- S O U IF APPLICABLE: 0 LAND USE PROJECT#(SEPA, PRE-APP, SS, ETC.) SITE WORK FOR PROJECT TYPE:❑SFR-DETACHED ❑SFR-ATTACHED El DUPLEX ❑MULTI-FAMILY ❑COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? 0 NO ❑YES, FROM TO NEW WATER/SEWER SERVICE NEEDED? ❑ NO ❑YES,TYPE SIZE SITE WORK/ RIGHT-OF-WAY APPLICATION INFORMATION DESCRIPTION OF WORK: Ve tA) 6 F t—).-/- -�--e9 ce i 0 ) r ►'J o.f Ct>c<_() 5 6 FENCE IN ROW 6 F'{' FT IN HEIGHT ❑ DRIVEWAY APRON/CURB CUT FT WIDE ❑ASPHALT/CONCRETE PAVING SF ❑ RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF ❑ RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT 0 CLEARING/GRADING/FILL/EXCAVATE CY 0 CUT/BORE IN PAVEMENT(PARALLEL) LF ❑ CUT/BORE IN PAVEMENT(NON-PARALLEL) LF CONTACT INFORMATION OWNER NAME: T Ips I Gtl6 U 64 OWNER MAILING ADDRESS: EET �(QLl I u �/� 5/ 2/ lllCl/llITTY EV I e I + STATE/il i\/l �/ ZIP 7g V x OWNER PHONE: Jt�o ' Q� - OI 6� OWNER EMAIL ) YL �j STALL �C(A�- S cti /LC tO a.Ca Ai APPLICANT NAME: I S t' C AS A Bo VL" APPLICANT MAILING ADDRESS: STREET CITY STATE ZIP APPLICANT PHONE: APPLICANT EMAIL: PRIMARY CONTACT: ❑ OWNER ❑APPLICANT ❑ OTHER(Architect, Engineer, Etc.) CONTACT NAME: CONTACT PHONE: /IM �� S / C d5 CV L CONTACT EMAIL: ACKNOWLEDGEMENT:I have reviewed this application and confirm the information contained herein is true and correct. Work done pursuant to this permit must 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 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 perform the work for which application is made,and I comply with the State Contractors Law 18.27 RCW and 296.200A WAC. City of Everett Official Use Only PERMIT# 1 z7 2, /x ,/ 16 Pwioa -- o'3B� Owner/. thorized Agent Sign re Date (Revised 10/12/2015)