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P LIC WORKS PERMIT A��LICATION S`��� <br /> � CITY OF EVERETT PERMIT SE(f 1 ti;ES <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: ' j � `� ;�: r�'i iti�i= �`J�,<J �= r-j'`�,<�J�`,�i' <br /> IF APPLICABLE: ❑ LAND USE PROJECT#(SEPA,PRE-APP,SS, ETC.) <br /> SITE WORK FOR PROJECT TYPE:�SFR-DETACHED ❑SFR-ATfACHED ❑DUPLEX ❑MULTI-FAMILY ❑COMMERCIAL ❑INDUSTRIAL <br /> CHANGE OF USE? �I.NO ❑YES, FROM TO <br /> NEW WATER/SEWER SERVICE NEEDED? �NO ❑YES,TYPE SIZE <br /> SITE WORK / RIGHT-OF-WAY APPLICATION INFORMATION <br /> DESCRIPTION OF WORK: ' � r �' , (,1(,y,,�/ , �(j ��, Gd �,V� L�� <br /> � �� VV1� �7 1��'� � �t1 - � �.� �'� ��• -�' � � <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 ��� �j [) CY <br /> ❑CUT/BORE IN PAVEMENT(PARALLEL) LF <br /> ❑CUT/BORE IN PAVEMENT(NON-PARALLEL) LF <br /> CONTACT INFORMATION <br /> OWNER NAME: � G` SS� ��" �l <br /> OWNER MAILING ADDRESS: srREEr }—j �� <br /> ,�� S+. <br /> CITY �j(„y"�� . . STATE � '�r� ZIP�' � Ll;� � <br /> OWNER PHONE: 2��'�"- �1��l�—� ��� OWNER EMAIL: +'lt',1 I�-��il\'►SS t���'' (��i"�'• (,1)MYt <br /> APPLICANT NAME: �L\Y�1 �: ) (, I�'��i <br /> APPLICANT MAILING ADDRESS: sraeEr <br /> CITY STATE ZIP <br /> APPLICANT PHONE: APPLICANT EMAIL: <br /> PRIMARY CONTACT: :�(OWNER $APPLICANT ❑OTHER(Architect, Engineer, Etc.) <br /> CONTACT NAME: ,,., Y p CONTACT PHONE: <br /> `�l'1"V��1"i.. <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.I am the owner,or I am authorized by the owner of this prope�ty to <br /> perform the work for which application is made, and I comply with the State Contracto�s Law 18.27 RCW and 296.200A WAC. <br /> City of Everett O�cial Use Only <br /> PERMIT# <br /> J� � � PW l6�.� -�'y� <br /> � �� ►� <br /> O ner/Authorized Agent Signature Date (Revised 10/12/2015) <br />