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PI IBLIC WORKS PERMIT APPLICATION <br /> CITY OF EVERETT PERMIT VICES <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> (P) 425-257-8810 J FAX 425-257-8857 J (E) everetteps@everettwa.gov www.everettwa.gov/permits <br /> PROJECT.SITE INIrORMATION <br /> PROJECT ADDRESS: 2 L D' ✓ ✓C�G -� <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? Q NO ❑YES,TYPE SIZE <br /> SITE WORK] RIGHT-OF-WAY APPLICATION INFORMATION <br /> _ . <br /> DESCRIPTION OF WORK: <br /> 0 C,vOr 0;-)/✓O CG7 ¢ O� RCS A10 C�t ci e Zoo � rends c I v ra e <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 I GRADING I FILL/EXCAVATE CY <br /> ❑ CUT/BORE IN PAVEMENT(PARALLEL) LF <br /> ❑ CUT/BORE IN PAVEMENT(NON-PARALLEL) LF <br /> CONTACT INFORMATION <br /> OWNER NAME: �' ;� L id1I CGJ C <br /> OWNER MAILING ADDRESS: STREET ( �, riNf ✓ J <br /> CITY STATE ZIP 97 <br /> OWNER PHONE: 2 -Z 5 Z ` G OWNER EMAIL: <br /> APPLICANT NAME: L ,� <br /> APPLICANT MAILING ADDRESS: STREET A, 1Z <br /> /. CITY G V �� STATE ZIP <br /> . j� APPLICANT EMAIL: <br /> APPLICANT PHONE: %y ' GiL C� �Z <br /> PRIMARY CONTACT: �0 OWNER lUAfIFLICANT ❑ OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: <br /> De J/ �/� CONTACT EMAIL: <br /> ACKNOWLEDGEMENT.,I 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 I 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 98.27 RCW and 296.200A WAC <br /> City of Everett official Use Only <br /> PERMIT# <br /> PW <br /> Owner/Authorized Agent Signature Date (Revised 90/92/2095) <br /> l <br />