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rr"'__`�L IC YNORKS PERNT :11pLOC A ION <br /> CITY OF EVERETT PERMIT SERVICES <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> (P) 425-257-8810 FAX 425-257-8857 1 (E) everetteps@everettwa.gov www.everettwa.gov/permits <br /> PROJECT siTE INFORMATION' <br /> PROJECT ADDRESS: Z C I L( t C <br /> IF APPLICABLE: ❑ LAND USE PROJECT#(SEPA,PRE-APP,SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:CISFR-DETACHED ❑SFR-ATTACHED ❑DUPLEX ❑MULTI-FAMILY ❑COMMERCIAL ❑INDUSTRIAL <br /> CHANGE OF USE? NO ❑YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? Pq NO ❑YES,TYPE _ SIZE <br /> SITE WORK I RIGHT-OF-WAY APPLICATION INFORMATION <br /> DESCRIPTION OF WORK: o'c- c Un <br /> v � <br /> ❑ FENCE IN ROW FT IN HEIGHT <br /> ❑ DRIVEWAY APRON/CURB CUT FT WIDE <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 1N PAVEMENT(PARALLEL) LF <br /> ❑ CUT/BORE 1N PAVEMENT(NON-PARALLEL) LF <br /> CONTACT INFORMATION <br /> OWNER NAME: <br /> OWNER MAILING ADDRESS: STREET p 60 X <br /> CITY STATE ZIP `\D <br /> OWNER PHONE: �Z S-3Zp- �q�' OWNER EMAIL: CA\ve­e_n QUA <br /> APPLICANT NAME: Q I'V e.- U'•-J\S <br /> APPLICANT MAILING ADDRESS: STREET-�>(:) <br /> CITY &"e-r'e-+t STATE UJV\ zip <br /> APPLICANT PHONE: APPLICANT EMAIL: <br /> PRIMARYCONTACT: [Ja,QWNER t`APPLICANT ❑1OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: <br /> C)vv.,6 r LeCONTACTEMAIL: O\t-ve,c� c o�h�ov�n� �'f5torc l en Cc7iv� <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 first be <br /> authorized in writing from the Building Official before being authorized under any circumstance.1 am the owner,or I am authorized by the owner of this property to <br /> perform the work for which pp/fcation 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 /> oil <br /> (Revised 10/12/2015) <br /> Owne Authorized Agent Signature Date <br />