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P1 19LIC WORKS PERMIT <br /> nPLICATION <br /> CITY OF EVERETT PERMITS kVICES <br /> 3200 CEDAR STREET, EVERETT, WA 98201 <br /> (P) 425-257-8810 FAX 425-257-8857 (E) everetteps@everettwa.gov www.everettwa.gov/permits <br /> PROJECT SITE INFORMATION <br /> PROJECT ADDRESS: 3`r< z l !�/• L 7 d ✓ = 7—/I <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 ❑YES,TYPE SIZE <br /> SITE WORK I RIGHT-OF-WAY APPLICATION INFORMATION <br /> DESCRIPTION OF WORK: <br /> ❑ FENCE IN ROW FT IN HEIGHT <br /> ❑ DRIVEWAY APRON/CURB CUT FT WIDE <br /> ❑ASPHALT/CONCRETE PAVING SF <br /> L�RETAINING WALL/ROCKERY IN RIGHT-OF-WAY / 3 G 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: ` 6'_E R 1 61/ O c lZ b <br /> OWNER MAILING ADDRESS: STREET ! ? <br /> CITY V-/_,71 c,1 r STATE �� ZIP O�D <br /> OWNER PHONE: 'la`s 7-7 3 OWNER EMAIL: tYlE-1!^o 6- �liu 'fiS''r�t tJ �t7lvtetST• dte, <br /> APPLICANT NAME: <br /> APPLICANT MAILING ADDRESS: STREET <br /> CITY STATE ZIP <br /> APPLICANT PHONE: APPLICANT EMAIL: <br /> PRIMARY CONTACT: ❑ OWNER ❑APPLICANT ❑ OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: CONTACT PHONE: <br /> 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.l 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 18.27 RCW and 296.200A WAC. <br /> City of Everett Official Use Only <br /> PERMIT# <br /> PWI � �- ' - <br /> Owner/Authorized Agent Signature Date (Revised 10/12/2015) <br />