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Pi ILIC WORKS PERMIT Ili PLICATION <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) everetteps@everettwa.gov I www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: ?j� -U '-j tfa-v A'iAa. <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? ❑ NO N YES,TYPE (yMIZ2- SIZE 2.1' <br /> SITE WORK / RIGHT-OF-WAY APPLICATION INFORMATION <br /> DESCRIPTION OF WORK: S <br /> -f? 4- w <br /> ❑ FENCE IN ROW FT IN HEIGHT <br /> DRIVEWAY APRON/CURB CUT Zti FT WIDE <br /> ❑ <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 /> ❑ CUT/BORE IN PAVEMENT(NON-PARALLEL) LF <br /> CONTACT INFORMATION <br /> OWNER NAME: 15 ,_., V l <br /> OWNER MAILING ADDRESS: STREET `` , 1 <br /> CI �� STATE W ZIP Ifs l v8 <br /> OWNER PHONE: OWNER EMAIL: <br /> APPLICANT NAME: Ku'ZIL-iG� PLL.1 V'&- <br /> APPLICANT MAILING ADDRESS: STREET zj <br /> CITY STATE ZIP <br /> APPLICANT PHONE: APPLICANT EMAIL: <br /> PRIMARY CONTACT: ❑ OWNER APPLICANT ❑ OTHER (Architect, Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: e <br /> � ML CONTACT EMAIL: <br /> ACKNOWLEDGEMENT.'1 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 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 /> PW 16 /Z 03A <br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015) <br />