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<br /> CITY OF EVERETT PERMIT SERVICES
<br /> 3200 CEDAR STREET, EVERETT, WA 982Q'1
<br /> (P)425-257-8810 � FAX 425-257-88�7 � (E) everetteps@everettwa.gov( www.everettwa.gov/permits
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<br /> ,: PROJECT SITE INFORMATION
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<br /> PROJECTADDRESS: ��„� Z- GY'GK� /� J�- JZ�'� '�` I/� � Z�
<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 NEE�ED? �NO ❑YES,TYPE SIZE
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<br /> ' SITE WORK�/ RIGHT OF-WAY APPLICATION`INFORMATI;vON ,,;:
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<br /> � � �DESCRIPTION OF WORK. G\ � �`
<br /> ❑ FENCE IN ROW FT IN HEIGHT
<br /> ❑ DRIVEWAY APRON/CURB CUT �W�pE
<br /> �ASPHALT/CONCRETE PAVING .`�' � �� !" -I"" SF
<br /> ❑ RETAINING WALL/ROCKERY IN RIGHT-OF-WAY LF
<br /> � RETAINING WALL/ROCKERY OVER 4FT IN HEIGHT FT TOTAL HEIGHT
<br /> � CLEARING/GRADWG/F1LL/EXCAVATE CY
<br /> ❑ CUT/BORE 1N PAVEMENT(PARALLEL) LF
<br /> ❑ CUT/B�RE IN PAVEMENT(NON-PARALLEL) LF
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<br /> CONTACT INFORMATION _
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<br /> OWNER NAME: -�-r� [.L.�� V l°e..l.� Ci�VI �� PIti�1�ti �j 2 �-S e,
<br /> OWNER MAILING ADDRESS: sTReeT l I � P'�f/� k�`
<br /> CITY ! STATE ~ � ZIP p
<br /> OWNER PHONE: �y ��P p ��� i �1 i S f'e.Ce`"''�
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<br /> OWNER EMAIL: � k.v�2. � � P
<br /> APPLICANT NAME:� �� ����r:�v✓�'M^ . W"�2.�-Q.�
<br /> APPL(CANT MAILING ADDRESS: s-rReer �Z..2�J Z- 5Ta-�� �
<br /> ciTv ��!��"t� � STATE GL�� zip �Z��
<br /> APPLICANT PHONE: �I2� Z.7 �SI APPLICANT EMAIL: 6 b w'� �r W0. l� ��"'�G' t` �d� _
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<br /> PRiMARY CONTACT: ❑ OWNER �APPLICANT ❑ OTHER(Architect, Engineer, Etc.)
<br /> CONT CT NAME: CONTACT PHONE: �� �'� f �j
<br /> �� � l � ��� �� COMTACT EMAIL: 'p �(� �ry-�t�� g ''''<<'� • C-��
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<br /> ACKNOWLEDGEMENT.�I have reviewed this application and confirm the information contained herein is true and correcf. Work done pursuant to this permit must
<br /> comply with currenf 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 Buifding Official before being authorized under any circumstance.1 am the owner,or 1 am authorized by the owner of fhis property to
<br /> perform the work for which application is made,and I comply with the State Contractors Law 98.27 RCW and 296.200A WAC.
<br /> City of Everett Official Use Only
<br /> PERMIT#
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<br /> Owner/Aufhorized Agent Signafure Date (Revfsed 10/12/2D95)
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