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Pt I IC WORKS PERMIT PLICATION CITY OF EVERETT PERMIT SERVICES 3200 CEDAR STREET, EVERETT, WA 98201 (P) 425-257-8810 1 FAX 425-257-8857 1 (E) everetteps@everettwa.gov I www.everettwa.gov/permits PROJECT SITE INFORMATION PROJECT ADDRESS: IF APPLICABLE: ❑ LAND USE PROJECT#(SEPA, PRE-APP, SS, ETC.) SITE WORK FOR PROJECT TYPE:❑SFR-DETACHED ❑SFR-ATTACHED ❑DUPLEX ❑MULTI-FAMILY []COMMERCIAL ❑INDUSTRIAL CHANGE OF USE? ❑ NO ❑YES, FROM TO NEW WATER/SEWER SERVICE NEEDED? ❑ NO ❑YES,TYPE SIZE SITE WORK / RIGHT-OF-WAY APPLICATION INFORMATION DESCRIPTION OF WORK: FENCE IN ROW 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 ❑ CLEARING/GRADING/FILL/EXCAVATE CY ❑ CUT/BORE IN PAVEMENT(PARALLEL) LF ❑ CUT/BORE IN PAVEMENT(NON-PARALLEL) LF CONTACT INFORMATION OWNER NAME: J EFF i OWNER MAILING ADDRESS: STREET CITY STATE 3 ZIP OWNER PHONE: 3 OWNER EMAIL: APPLICANT NAME: APPLICANT MAILING ADDRESS: STREET CITY STATE ZIP APPLICANT PHONE: APPLICANT EMAIL: PRIMARY CONTACT: WNER ❑APPLICANT ❑ OTHER(Architect, Engineer, Etc.) CONTACT NAME: CONTACT PHONE: • 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 l comply with the State Contractors Law 18.27 RCW and 296.200A WAC. City of Everett Official Use Only PERMIT# _AiiLo � PW 160 7- -01-3 OWneVlAuthorized Agent Signature Date (Revised 10/12/2015)