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Mar 18 16 11:44a Sharon Zeh 425-259-4068 P.1 <br /> ` PUBLIC WORKS PERMIT APPLICATION <br /> CITY OF EVERETT- PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> (P) 425-257-8810 1 FAX 425-257-8857 1 (E) ev eretteps cv erettw�.g ov w vw.avereawa.govi p c r m its <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: <br /> IF APPugABLE: ❑ LAND USC PROJECT# (S EPA, PRE-APP, S_, FT(--.) <br /> SITE WORK FOR PROJECT TYPE: SFR-DETACI"9ED ❑SFR-ATTACHEo ❑DUPLEX 13MI-11 TI-FAVi-Y 11c0r,9 AERCIAL E79NDUSTRIAL <br /> CHANGE OF USE? RNO © YES, FROM. TO <br /> NEW WATER I SEWER SERVICE NEEDED? aNO ❑ YES. -YPE SIZE <br /> SITE WORK I RIGHT-OF-WAY APPLICATION INFORMATION <br /> DESCRIPTION OF WORK: <br /> lj�FENCE IN ROW FT IN HEIGHT <br /> ❑ DRIVEWAY APRON/CURB CUT FT WIDE <br /> ❑ASPHALT/CONCRETE PAVI NG SF <br /> ❑ RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF <br /> ❑ RETAINING WA-L/ROCKERY OVER 4FT IN HEIGHT FT TO I'AI_ HEIGHT <br /> ❑ CLEARING/GRADING i FILL i EXCAVATE C <br /> [ICU F;BOPF- IN PAVEMENT (PARALLEL} LF <br /> ❑CUTiBORE IN PAVEMENT (NON-PARALLEL) LF <br /> CONTACT INFORMATION <br /> OWNER NAME: <br /> OWNER MAILING ADDRESS: STREET <br /> C:Tv / <br /> G � STATE`/ /� ZIF <br /> OWNER PHONE: .1 1,121 � ? — S 7/ OWNER EMAIL: - " <br /> ixl <br /> APPLICANT NAME: <br /> APPLICANT MAILING ADDRESS: STREET <br /> CI1Y ���GS STATE &2 ZIP <br /> APPLICANT PHONE: ,.Z - 3,Z 7- y-) 7/ 1APPLICANT EMAIL: <br /> PRIMARY CONTACT: OWNER ❑APPLICANT ❑OTHER(Arai, �_, E,-- E«.) <br /> CONTACT NAME: CONTACT PHONE: <br /> CONTACT EMAIL: ,J <br /> ACKNOWLEDGEMENT:l have reviewed this application and confirm the information contained herein is true and correct. Work done 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 fust be <br /> authorized in writing frorn the Building Cfficial before being authonzed under any circumstance. t am the owner, or/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 /> i > <br /> CL <br /> Cit of Everett Official Use Only <br /> PERMIT 9 <br /> pw160 -051 <br /> Owner/Authorized Agent Signature D— (Revised 10/12,2015) <br />